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SURGICAL  DISEASES   OF    CHILDREN 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/surgicaldiseasesOOkell 


SURGICAL  DISEASES 

OF 

CHILDREN 

A  MODERN  TREATISE  ON 

PEDIATRIC   SURGERY 


By 
SAMUEL  W.  KELLEY,  M.D.,  LL.D. 

Honorary  Professor  of  Surgical  Diseases  of  Children,  Medical 

Department,  National  University,  St.  Louis  ;  Pediatrist  and 

Orthopedist,    St.   Luke's   Hospital,   Cleveland;   Formerly 

Professor    of    Diseases    of    Children,    Cleveland 

College  of  Physicians  and  Surgeons,  Medical 

Department,  Ohio  Wesleyan  University 


ILLUSTRATED 


SECOND  EDITION,  REVISED  AND  ENLARGED 


E.  B.  TREAT  &  COMPANY 

NEW  YORK 
1914 


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Copyright,  1909,  1914, 
By  E.  B.  treat  &  CO. 


1?  J  5  a  G 


3\4- 


To  any  hapless  child, 
Crippled,  injured,  ill. 
And  to  any  doctor 
Who  sees  and  fain  would   help. 
This  hook  is  dedicated. 


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^ 


PREFACE  TO  SECOND  EDITION. 

There  is  still  need  to  extend  the  knowledge  and  the  practice 
of  the  surgery  of  infancy  and  childhood  and  reviewers  and  prac- 
titioners have  given  such  general  approval  to  the  first  edition  that 
author  and  publishers  feel  encouraged  to  produce  a  second  edition. 
One  of  the  reviewers  ^  shows  so  keen  an  insight  into  the  intent  and 
scope  of  the  book  and  expresses  it  so  clearly  that,  in  presenting  the 
second  edition,  I  cannot  do  better  than  to  quote  his  words.  "This 
volume  is  in  every  sense  something  more  than  a  mere  chronicle  of 
surgical  pediatrics.  It  strives  at  and  attains  a  higher  goal.  There 
is  a  clear  and  consistent  efifort  to  present  to  the  careful  reader  the 
practical  essential  differences  between  child-surgery  and  adult- 
surgery;  between  child-pathology  and  adult-pathology.  Nor  is 
this  all — the  book  is  new  and  up-to-date  in  the  best  sense  because 
it  not  alone  gives  full  credence  and  value  to  the  importance  of  ex- 
perimental medicine  and  surgery,  but  painstakingly  seeks  to  make 
clear  the  relationship  and  inter-dependence  of  the  surgery  which  in 
the  past  has  erroneously  been  called  'practical'  and  that  which  has 
with  equal  error  been  styled  'theoretical'  or  'experimental.'  The 
author  has  wisely  decided  that  modern  surgery  must  necessarily 
be  a  combination  of  the  two  and  the  skill  with  which  he  has  woven 
the  intricate  woof  of  modern  surgical  physiology  and  pathology  into 
the  strong  basic  warp  of  well-recognized  surgical  principles  seems 
to  the  reviewer  the  most  admirable  fact  of  the  entire  work.  Finally 
the  author's  great  care  in  presenting  essential  details  should  be 
commented  on  favorably " 

In  making  changes  for  the  second  edition  I  have  endeavored  to 
live  up  to  the  principles  integral  in  the  first  and  have  also  given 
due  consideration  to  and  endeavored  to  profit  by  all  criticisms. 

Considerable  new  matter  has  been  added — not  every  thing  new 
that  has  been  proposed — but  such  as  will  likely  have  permanent  in- 
terest and  value.  A  few  subjects  have  been  entirely  rewritten. 
Among  more  than  a  hundred  emendations,  may  be  mentioned : 

Transfusion  with  Brewer's  tubes,  arthroplasty,  motion  after 
dislocation  and  other  joint  injuries,  anomalies  and  deformities  of 
the  skull,  Abbott's  method  for  scoliosis,  tonsillectomy,  fistulae  and 
cysts  of  the  neck,  Cook's  operation  for  relapsed  clubfoot.     Altera- 

1  N.  Y.  Medical  Record,  July  24,  1909. 


PREFACE  TO  SECOND  EDITION 

tions  have  been  made  mainly  by  insertions  and  condensations  so 
that  there  are  only  25  more  pages  in  the  entire  book.  A  number  of 
notes  have  been  placed  in  the  form  of  an  appendix,  with  appropriate 
reference  numerals  in  the  main  text.  I  have  adhered  to  the  plan 
of  avoiding  statistical  arguments  as  too  cyclopedic  for  the  scope  of 
this  v^''ork,  and  have  introduced  case  reports  only  where  the  concrete 
example  would  serve  better  than  a  general  statement  to  present  the 
subject.  A  number  of  new  illustrations  have  been  added.  The 
book  is  offered  with  a  realization  of  its  limitations,  but  in  the  hope 
that  it  will  be  equally  as  well  accepted  as  the  first  edition ;  and  that 
it  will  be  even  more  widely  read,  for  never  before  has  the  growth  of 
interest  in  the  subject  been  equal  to  that  of  recent  years. 

SAMUEL  W.  KELLEY. 

Cleveland,  Ohio,  August,  1913. 


HISTORICAL  AND   PREFATORY 

Surgical  pediatrics  was  later  and  slower  in  :  ts  development  as 
a  special  department  of  study  and  practice  than  medical  pediatrics. 

As  is  well  known,  numerous  writers  from  the  ancients  down 
have  alluded  to  the  behavior  of  disease  in  children — the  surgical 
occasionally,  as  well  as  the  medical — and  yet  as  late  as  1846,  when 
Coley  wrote  an  introduction  to  his  "  Practical  Treatise  on  the  Dis- 
eases of  Children."  he  made  the  following  statement:  "I  am  not 
aware,  however,  that  any  author,  British  or  foreign,  has  published 
a  work  comprehending  all  the  diseases  incident  to  children  and 
their  appropriate  surgical,  as  well  as  medical,  treatment.  This 
omission  may  be  accounted  for  by  the  division  of  the  profession, 
which  has  limited  the  education  and  practice  of  physicians  who 
have  hitherto  been  the  principal  or  only  writers  on  infantile  ais- 
orders." 

This  remark  Dr.  Coley  makes  after  professing  himself  ac- 
quainted among  modern  writers,  with  the  works  of  Astruc,  Arm- 
strong, Hamilton,  Cheyne,  Heberden,  Becker,  Plenk,  Burns, 
Capuron,  Clarke,  Gardien,  Comet,  Golis,  Dewees.  Underwood,  Bil- 
lard,  Aleissner,  Marley,  Maunsell  and  Evanson,  Barrier,  Barthez 
and  Rilliet,  Rees,  etc.  I  am  ready  to  vouch  that  Dr.  Coley's  state- 
ment is  well  founded,  for  on  perusal  of  many  of  the  authors  he  men- 
tions, and  others  not  in  his  list,  it  becomes  evident  that  none  of  them 
had  given  adequate  attention  to  the  surgical  side  of  children's 
diseases. 

Take,  for  example.  Underwood — writing  in  1795 — who  devoted 
188  pages,  or  Part  I.,  of  his  second  volume  to  "  All  such  complaints 
as  may  fall  under  the  province  of  the  surgeon,  with  others  that 
may  be  said  to  be  of  a  mixed  kind  which,"  as  he  says,  "  should 
be  all  familiar  to  every  accoucheur."  But  Underwood  addressed 
his  text  as  much  to  the  laity  as  to  the  profession,  and  there  is  lit- 
tle or  nothing  in  it  to  enlighten  or  guide  the  surgeon.  Even  John 
Syer,  surgeon,  of  London — who,  being  a  surgeon,  might  be  ex- 
pected to  do  better  in  this  respect — in  his  treatise  written  in  1812, 
presented  no  topics  which  might  be  called  surgical,  excepting  puru- 
lent ophthalmia,  croup,  and  rickets.  Under  croup,  he  did  not  even 
mention  operative  measures.  However,  tracheotomy,  although 
known,  was  little  esteemed  until  Trousseau's  revival  of  it  in  1850-57. 
As  to  rachitis,  Syer  gave  no  definite  account  of  the  deformities,  and 


8  HISTORICAL  AND  PREFATORY 

only  a  general  description  of  deformity  apparatus.  For  these,  as 
for  other  diseases,  he  presented  "  The  General  Principles  of  Their 
Domestic  Treatment," 

Dewees'  "  Treatise  on  the  Physical  and  Medical  Treatment  of 
Children"  (1826)  included  ophthalmia,  croup,  hip-disease,  hydro- 
cele, hernise,  and  several  skin  affections,  but  even  these  few  surgi- 
cal topics  cannot  be  said  to  have  been  handled  surgically. 

Eberle's  book  (1833)  had  practically  nothing  surgical.  Billard 
— the  English  translation  of  whose  work  appeared  in  1839 — included 
in  his  treatise  diseases  of  the  skin,  hernise,  prolapse  of  the  rec- 
tum, intussusception  (at  least  the  kind  found  postmortem),  mal- 
formations of  various  parts,  and  also  fractures — intrauterine  and 
of  the  new-born.  But  he  pointed  out  no  differences  between  those 
abnormalities  and  similar  conditions  in  the  adult,  nor  did  he  give 
the  treatment  for  them.  His  attention  was  centered  on  "  Recent 
Clinical  Observations  and  Investigations  in  Pathological  Anat- 
omy," for  this  was  the  period  of  a  new  enthusiasm  in  that  branch 
of  medical  science. 

Evanson  and  Maunsell  (1843)  included  syphilis,  rachitis,  skin 
diseases,  foreign  bodies  in  the  larynx,  fractures,  herniae,  nevi, 
tongue-tie,  hare-lip,  spina  bifida  and  ophthalmia,  imperforate  anus, 
and  various  deformities  of  the  genito-urinary  organs.  Although 
they  sometimes  advised  and  described  the  treatment  then  con- 
sidered appropriate  for  these  difficulties,  their  general  attitude  seems 
to  be  expressed  in  a  remark  which  appeared  in  connection  with 
making  an  artificial  anus  in  the  groin  (page  138),  as  follows  :  "  The 
operation  would  be  a  very  hopeless  one ;  but  a  consideration  of  its 
merits,  and  of  the  exact  modes  of  performing  the  other  operations, 
belong  rather  to  the  province  of  the  surgeon  than  of  the  child's 
physician — who,  in  that  capacity,  has  merely  to  ascertain  the  nature 
of  the  deformity,  and  must  draw  upon  his  own  general  knowledge 
of  surgery  or  apply  to  another  practitioner  for  the  means  of  its 
removal." 

These  authors  mentioned  are  but  examples.  Others  who 
might  be  cited — for  instance,  Stewart  (1843) — were  much  like 
them.  So  that  it  appears  to  be  true  that  physicians  had  until  then 
"  been  the  principal  or  only  writers  upon  infantile  disorders,"  and 
had  made  little  progress  in  surgical  pediatrics. 

But  Coley  purposed,  as  every  good  author  should,  to  do  bet- 
ter than  his  predecessors,  and  in  the  matter  of  surgicar  diseases  he 
in  some  degree  succeeded.  He  not  only  discoursed  on  the  herniae, 
imperforate  anus,  clubfoot  and  other  distortions,  hare-lip,  laryn- 
gotomy  and  tracheotomy,  foreign  bodies  swallowed  or  lodged  in  the 
pharynx  or  in  the  vermiform  appendix,  prolapsus  ani,  pyothorax, 
vesical  and  urethral  calculus,  imperforate  urethra  and  vagina,  phi- 


HISTORICAL  AND  PREFATORY  9 

mosis  and  paraphimosis,  diseases  of  the  joints,  burns  and  scalds, 
spina  bifida,  and  other  surgical  topics,  but  he  advised  and  described 
the  surgical  treatment  which  experience  or  the  literature  up  to  his 
time  had  taught  him.  He  also  treated  of  diseases  of  the  eyes  and 
of  the  skin  quite  extensively.  But  Coley's  book  seems  to  have 
attracted  little  attention, 

J.  Forsyth  Meigs,  writing  in  1848,  presents  nothing  surgical, 
although  his  work  more  nearly  equaled  the  quality  of  those  on  gen- 
eral medicine  than  had  any  upon  diseases  of  children  up  to  that 
time.  Nor  can  the  lectures  of  Charles  West,  the  most  admirable 
clinician  and  oft-quoted  writer  of  his  time,  be  said  to  deal  with 
both  sides  of  his  subject. 

In  Churchill  (1850),  a  few  topics,  as  tracheotomy,  paracen- 
tesis for  pleurisy,  hare-lip,  cleft  palate,  imperforate  anus,  and  spina 
bifida,  receive  some  surgical  handling.  Condie  does  not  consider 
that  surgical  subjects  fall  within  the  scope  of  his  treatise. 

But  by  this  time  the  knowledge  of  anatomy,  of  physiology,  of 
pathology,  and  of  the  history  of  diseases  and  injuries  had  increased 
to  such  an  extent,  the  observations  of  practical  surgeons  had  so 
accumulated,  and  the  establishment  of  hospitals  for  children  had 
so  improved  the  facilities  for  the  study  of  their  diseases  that  their 
peculiarities  and  their  importance  could  no  longer  be  quite  ignored 
by  the  profession. 

About  the  year  1850,  in  Paris,  while  Trousseau  taught  the 
diseases  of  children,  the  surgical  side  was  taught  by  Giraldes,  who, 
however,  published  little  in  permanent  form  until  later. 

In  1855,  J.  C.  Forster,  in  London,  had  been  making  "  A  few 
remarks  on  the  surgical  diseases  of  children,"  arid  in  i860  his  8vo 
volume  was  published.  It  was  also  in  the  year  i860  that  A.  A.  W. 
Johnson  delivered,  at  the  Hospital  for  Sick  Children,  a  course  of 
"  Lectures  on  the  Surgery  of  Childhood." 

In  1863  we  find  that  the  Council  of  the  Medical  Society  of  Lon- 
don, "  recognizing  the  importance  of  this  subject,  have  been  led  to 
believe  that  the  interests  of  its  members  might  be  promoted  and 
the  profession  benefited  by  having  their  attention  drawn  from  the 
broad  field  of  general  medicine  and  surgery  to  the  comparatively 
small  one  of  the  diseases  of  children,  and  on  the  strength  of  this 
belief  have,  abandoning  the  custom  by  which  they  have  been 
hitherto  bound,  defined  the  subjects  for  the  Lettsomian  lectures," 
and  they  nominated  as  lecturer,  Mr.  Thomas  Bryant,  who  delivered 
three  admirable  lectures  on  the  surgical  diseases  of  children. 

M.  Giraldes,  in  Paris,  had  been  followed  as  the  leading  teacher, 
by  Guersant,  whose  "  Notices  sur  la  Chirurgie  des  Enfants,"  a 
series  of  very  pointed  and  practical  papers,  found  their  way  into 
an  English  translation  for  publication  about  the  same  time. 


10  HISTORICAL  AND    PREFATORY 

The  work  with  both  scalpel  and  pen,  of  the  pioneers  in  this  spe- 
cial line,  had  now  become  so  valuable  that  still  further  interest  was 
aroused  and  talent  engaged  in  its  behalf. 

In  1869,  Timothy  Holmes  issued  his  "  Surgical  Treatment  of 
Children's  Diseases,"  a  book  of  nearly  700  pages,  and  in  quality 
well  worthy  of  its  great  author. 

You  will  please  observe  that  Holmes  omitted,  from  the  first 
edition,  some  special  subjects,  viz.,  diseases  of  the  eye  and  ear, 
orthopedics  and  diseases  of  the  skin,  "  not,"  he  says,  "  because  I  am 
in  favor  of  cutting  up  surgery  into  little  pieces,  but  because  the  vol- 
ume had  already  exceeded  what  I  had  intended,  and  these  subjects 
are  all  excellently  treated  in  works  which  are  in  everybody's  hands." 
However,  in  the  second  edition — yielding  to  a  sense  of  the  fitness  of 
things — he  added  a  chapter  on  orthopedics.  I  mention  this  point 
in  particular  to  illustrate  the  fact  that  the  other  specialties  had 
advanced  so  much  faster  than  pediatrics,  and  particularly  than  sur- 
gical pediatrics,  as  to  have  completely  outstripped  it  in  develop- 
ment as  a  distinct  branch  of  our  profession. 

This  statement  is  capable  of  verification  by  reference  to  the 
history  of  the  other  branches,  and  is  particularly  shown  by  the 
specialties  of  the  eye  and  ear,  skin  diseases  and  orthopedics,  and 
later  gynecology.  Obstetrics,  which,  synchronously  with  anatomy, 
had  become  separated  in  the  work  of  the  medical  schools  from  sur- 
gery, had  remained  in  practice  more  distinctly  in  the  hands  of  the 
general  practitioners.  But  obstetrics,  fecundated  by  its  former 
companion,  surgery,  gave  birth  to  a  charming  daughter,  gynecol- 
ogy, who  soon  grew  to  maturity,  came  out  in  society  with  the 
greatest  eclat,  became  the  reigning  belle,  and  turned  the  heads  of 
many  susceptible  young  men  for  a  long  season.  Thus  gynecology, 
with  other  specialties,  chronologically  took  the  lead  of  surgical 
pediatrics. 

It  is  curious  to  observe  in  this  connection  that  the  "  Com- 
pendium of  Children's  Diseases,"  of  Johann  Steiner,  of  Prague, 
which  appeared  about  this  same  time,  had  for  its  English  translator 
no  less  a  personage  than  Lawson  Tait,  who  added  a  few  notes  on  the 
"  Surgical  Ailments  of  Children."  One  can  but  speculate  on  what 
might  have  happened  if  Lawson  Tait  had  felt  a  greater  attraction 
for  surgical  pediatrics  than  for  gjnecology. 

But  my  cursory  sketch  has  brought  me  down  to  times  almost 
within  the  recollection  of  the  majority  of  my  readers.  You  are 
familiar  with  the  record  of  the  last  thirty  and  the  magnificent  work 
of  the  last  twenty  years  in  the  surgical  diseases  of  children. 

To  continue  a  comparison  among  the  recent  achievements  of 
those  still  active  in  professional  life  would  require  a  nicer  discrim- 
ination  and   might   involve   greater   consequences   than   I   care   to 


HISTORICAL   AND    PREFATORY  ii 

assume ;  but  I  may  at  least  mention,  in  passing,  and  almost  at  ran- 
dom, the  names  of  Pooley,  Marsh,  St.  Germain,  Fumagalli,  Bas- 
sini,  Willard,  Ribiera  y  Sans,  R.  W.  Parker,  Charon  and  Gavaert, 
Karewski,  McEwen,  McClellan,  Keen,  Ridlon,  Taylor,  Wharton, 
Packard,  Morris,  Morton,  Phocas  and  O'Dwyer,  Senn  and  Murphy, 
Fenger  and  Matas,  Stiles,  Kirmisson,  Broca,  Frolich  and  Estor, 
although  I  have  omitted  scores  of  worthy  authors,  brilliant  in- 
vestigators, and  able  practitioners,  whose  writings  have  been 
turned  to  account  in  this  field.  Some  of  them  I  shall  have 
occasion  to  credit  later,  but  shall  make  no  attempt  to  give 
numerous  references  to  the  literature  consulted.  I  have  freely 
availed  myself  of  the  clinical  and  pathological  writings  of  medi- 
cal pediatric  teachers  of  the  present  time,  whose  names  are  famil- 
iar to  all  who  work  with  children.  But  I  must  here  express  my 
admiration  for  those  surgical  works  which  have  been  presented  to 
the  English  reading  profession  by  Timothy  Holmes,  Edmund  Owen, 
and  D'Arcy  Power  in  special  treatises,  by  G.  A.  Wright,  and  by 
numerous  contributors  to  Keating's  great  cyclopedia,  and  acknowl- 
edge my  indebtedness  to  their  guidance  in  my  practical  studies  of 
the  surgery  of  childhood.  I  have  endeavored  to  pay  my  debt  to 
them  and  to  the  profession  by  adding  my  own  mite  of  observation 
and  experience.  At  the  date  of  this  writing  no  American  has  yet 
produced  a  book  devoted  entirely  to  pediatric  surgery,  and  to  adapt 
a  treatise  to  present  conditions  of  medical  education  and  practice 
must  be  regarded  as  a  pioneer  endeavor.  We  are  yet  far  from  the 
ideal  state,  either  of  the  study  or  the  practice  of  surgical  pediatrics. 

I  am  indebted  to  Dr.  Wm.  J.  Butler,  of  Chicago,  for  the  Sec- 
tions on  Opsonins,  Opsonic  Index  and  Vaccine  Therapy,  and  on  the 
Diagnosis  of  Syphilis  from  the  Blood ;  and  to  Dr.  Homer  J.  Hart- 
zell  and  Dr.  Henry  Jenkins,  of  Cleveland,  for  work  upon  the  Index. 

My  thanks  are  due  the  publishers  for  their  liberality  in  extend- 
ing the  size  of  the  work  far  beyond  the  bounds  at  first  projected 
and  permitting  an  equally  generous  use  of  illustrations. 

The  illustrations,  excepting  otherwise  marked  and  credit  given, 
are  nearly  all  of  them,  from  photographs  taken  and  sketches  made 
by  myself. 

S.  W.  K. 

Cleveland^  Ohio.  ' 


CONTENTS 

CHAPTER  PAGE 

I.     EXAMINATION,    CASE-TAKING    AND    GENERAL    SUB- 
JECTS      25 

Examining  and  Case-Taking — Preparation  for  and  Management 
at  the  Operation — Anesthetics — Asepsis  and  Antisepsis — Ban- 
daging, Dressing  and  the  Application  of  Splints — Hemorrhage 
and  its  Control — Shock — After  Operation — Lavage,  Gavage  and 
Rectal   Feeding — Anatomy,   Growth   and   Development. 

IL     GENERAL     SURGICAL     PATHOLOGY     OF    THE    DE- 
VELOPING  PERIOD 59 

Malformations  —  Giantism  —  Acromegaly  —  Achondroplasia — 
Tumors  in  Infancy  and  Childhood — Retention  Cysts. 

in.     CONCERNING     CERTAIN      CONSTITUTIONAL     DIS- 
EASES   96 

Hemophilia — Rachitis   or   Rickets — Infantile   Scorbutus, 

IV.  VARIOUS  INFECTIONS  AND  THEIR  EFFECTS,  AND 

NON-INFECTIOUS    GANGRENE 112 

Tuberculosis  —  Syphilis  —  Sapremia  —  Septicemia  —  Pyemia — 
Surgical  Scarlet  Fever — Diphtheria  and  Pseudo-Diphtheria — 
Erysipelas — Cellulitis — Acute  Diffuse  Cellulitis — Tetanus  or 
Lockjaw — Other  Infections — Actinomycosis — Gangrene,  Infec- 
tious and  Non-Infectious. 

V.  BURNS  AND  SCALDS IS4 

Effects — Dangers — Diagnosis— -Prognosis — ^Treatment. 

VL    THE    MUSCLES,    TENDONS,    FASCIA,    BURS^    AND 

CELLULAR    TISSUES .     160 

Hematoma  of  the  Sternomastoid — Rheumatic  Myositis — Other 
Forms  of  Wry  Neck  (Torticollis) — Primary  Progressive  _  My- 
opathy— Tendons  and  their  Sheaths — Rheumatic  Tendinous 
Nodules — Injuries  of  Tendons  and  their  Sheaths — Operations 
upon  Tendons — Fasciae — Bursse — Cellular  Tissues. 

VII.    RICKETY  DEFORMITIES 181 

Genu  Valgum  (Knock-Knee) — Genu  Extrorsum  (Genu 
Varum) — Bow-Legs,  Corkscrew  and  Saber-Legs — Rickety  De- 
formities of  the  Forearm — Rickety  Deformities  of  the  Thorax. 

VIIL     DISEASES  OF  PERIOSTEUM,  BONES,  AND  JOINTS 

NON-TUBERCULAR 198 

Acute  Periostitis — Acute  Osteomyelitis — Acute  Epiphysitis 
(Acute  Anthritis  of  Infants) — Syphilitic  Diseases  of  Bones, 
Periosteum,  Joints  and  Cartilages — Traumatic  Arthritis — Gono- 
coccus  Arthritis — Chronic  Secondary  Infective  Osteo-Arthritis 
— Non-Inflammatory  Arthropathies — Osteo-Arthritis  (Rheu- 
matoid Arthritis) — Joint   Changes   in   Hemophilia. 

15 


i6  CONTENTS 

CHAPTER  PAGE 

IX.  TUBERCULOSIS    OF   BONES   AND   JOINTS    .         .         .223 
Bone    Tuberculosis — Joint    Tuberculosis — Tubercular    Arthritis 

of  the  Hip — Tuberculosis  of  the  Knee-joint — Tuberculosis  of 
the  Ankle— Tarsal  Tuberculosis— Tuberculosis  of  the  Elbow — 
Tuberculosis  of  the  Shoulder— Wrist-Joint  Tuberculosis— Sacro-  ■ 
Iliac  Disease— Tubercular  Dactylitis— Tuberculosis  of  the 
Sterno-Clavicular  Joint — Tuberculosis  of  the  Ribs  and  their 
Cartilages — Tuberculosis  of  other  Bones. 

X.  FRACTURES  AND   SEPARATION   OF  EPIPHYSES        .     271 
Intra-Uterine  and  Congenital  Fractures — Incomplete  or  Green- 
stick    Fractures— Refracture    for   Vicious    Union — Fractures    of 

the  Skull — Fractures  of  Nasal  Bones — Fractures  of  the  Supe- 
rior Maxillary  and  Malar  Bones — Injuries  of  the  Humerus — 
T  or  Y  Fracture — Fracture  of  the  Internal  and  External  Con- 
dyle— Fracture  of  the  Internal  and  External  Epicondyle — Sepa- 
ration of  the  Upper  and  Lower  Epiphysis  of  Radius — Fracture 
of  Shaft  of  Radius  or  Ulna — Fracture  of  Shaft  of  Femur — 
Fractures  of  Shafts  of  Tibia  and  Fibula— The  Patella  and  Tu- 
bercle of  the  Tibia — Metacarpal  and  Phalangeal  Fractures — 
Fractures  of  the  Ribs — Fractures  of  Sternum. 

XL  DISLOCATIONS,  CONGENITAL  AND  ACQUIRED  .  299 
Abnormal  Laxness  of  Joints — Congenital  Dislocations  of  the 
Hip,  Knee,  Shoulder  and  various  other  Joints — Traumatic  Dis- 
locations— Dislocation  of  Radius  and  Ulna  Backward  and  For- 
ward— Subluxation  of  Radius — Dislocation  of  the  Radius  For- 
ward and  Backward — Dislocations  of  the  Shoulder,  Hip,  Pa- 
tella, and  Thumb — Dislocations  of  the  Phalanges,  Sternum  and 
Ribs — Compound   Dislocations. 

XIL     SURGICAL  DISEASES  OF  THE  LYMPHATICS     .         .     322 

The  Status  Lymphaticus  (Lymphatism) — Hyperplasia  of  the 
Lymph  Tissues  of  the  Pharynx  and  Naso-Pharynx — Primary 
and  Secondary  Tumors  of  the  Lymph  Vessels  and  of  the 
Lyrnph  Glands — Lymphangiectasis,  Lymphadenoma  and  Lymph 
Varix— Simple  Acute  Lymphadenitis  —  Acute  Septic  Lym- 
phadenitis— Simple  Chronic  or  Subacute  Lymphadenitis — Tuber- 
cular Lymphadenitis  —  Syphilitic  Lymphadenitis  —  Hodgkin's 
Disease. 

XIIL    THE  HEAD  AND  BRAIN 339 

Congenital  Cranial  Meningocele  and  Encephalocele — Fractures 
of  the  Skull — Prolapsus  and  Hernia  Cerebri — Traumatic  Cranial 
Meningocele  or  Traumatic  Cephalhydrocele — Pneumatocele 
Cranii  —  Cephalhematoma  —  Microcephalus  —  Hydrocephalus 
—Intracranial  Tumors — Cranio-Cerebral  Topography — Opera- 
tions upon  the  Cranium. 

XIV.    DEFORMITIES  AND  DISEASES  OF  THE  EAR  AND 

INTRACRANIAL    EXTENSION    OF    EAR   DISEASE    369 

Absence  or  Malformation  of  the  Auricle — Over-Development 
and  Prominence  of  the  Auricle — Fistula  in  Auris  Congenita — 
Common  Affections  of  the  External  Ear — The  Meatus  Audi- 
torius  Externus — Diphtheritic  Inflammation  of  the  Ear — In- 
juries of  the  Tympanic  Membrane — Myringitis — Inflammation 
ofthe  Middle  Ear — Incision  of  the  Membrana  Tympani — Mas- 
toiditis— Infective  Thrombosis  of  the  Lateral  Sinus — Intra- 
cranial Extension  of  Ear  Disease  to  the  Meninges  or  the  Brain. 


CONTENTS  17 

CHAPTER  PAGE 

XV.     THE   PARALYSES   OF   INFANCY   AND    CHILDHOOD 

AND   OPERATIONS  UPON   NERVES    .         .         .         .393 
The    Paralyses    of    Infancy    and    Childhood — Erb's    Paralysis — 
Acute  Anterior  Poliomyelitis  (Infantile  Spinal  Paralysis;  Acute 
Atrophic  Spinal   Paralysis;   Myelitis  of  the  Anterior   Horns) — 
Cerebral  Paralyses. 

XVL    THE     SPINE 417 

Spina  Bifida — ^Malformation  of  the  Sacrum — The  Normal  Curves 
of  the  Spine — Lateral  Curvature  or  Rotary-Lateral  Curvature 
(Scoliosis) — Tuberculosis  of  the  Spine  (Pott's  Disease);  Caries 
of  the  Spine;  Spondylitis. 

XVII.  SURGERY  OF  THE  AIR  PASSAGES  .  .  .  .450 
Malformation  and  other  Obstructions  of  Nasal  Passages — Falls 
or  Blows  upon  the  Nose — Neoplasms  in  the  Nose — Hyperplasia 
of  the  Lymph-Tissues  of  the  Pharynx  and  Naso-Pharynx — En- 
larged Tonsils — The  Uvula — Obstruction  of  the  Soft  Palate — 
Foreign  Bodies  in  the  Nose — Foreign  Bodies  in  the  Gullet — 
Chronic  Retro-Pharyngeal  Abscess. 

XVIIL  SURGERY  OF  THE  AIR  PASSAGES— Continued  .  477 
Edema  Glottidis — Acute  Simple  Laryngitis — Spasmodic,  Syphi- 
litic and  Tubercular  Laryngitis — Tumors  of  the  Larynx — 
Foreign  Bodies  in  the  Larynx,  Trachea  and  Bronchi — Mem- 
branous Laryngitis  (Membranous  Croup;  Diphtheritic  Croup; 
True  Croup) — Aeroporotomy — Thymic  Asthma;  Thymic  Tra- 
cheostenosis; Thymectomy. 

XIX.  THE  THORAX 512 

Its  Anatomy  in  Infancy  and  Childhood — Deformities  of  the 
Thorax — Tumors,  Caries  and  Abscesses  of  Thorax — Empyema. 

XX.  THE    ABDOMEN,    ITS    MALFORMATIONS   AND    DIS- 

EASES          532 

Its  Anatomy  in  Infancy  and  Childhood — Omphalitis — Arteritis 
and  Phlebitis — Septic  Peritonitis — Umbilical  Hemorrhage — 
Paralysis  of  Abdominal  Muscles — -Acute  Peritonitis — Appendi- 
citis— Chronic  (Non-tubercular)  Peritonitis — Tubercular  Peri- 
tonitis. 

XXI.  THE  ESOPHAGUS,  STOMACH  AND  INTESTINES     .     562 
Malformation  of  the  Esophagus — Foreign  Body  in   Esophagus 

— Stricture  of  the  Esophagus — Pyloric  Stenosis — Malformations 
of  the  Small  Intestines  and  Colon — Intussusception — Foreign 
Body  in  Stomach,  Intestine  or  Rectum — Fecal  Impaction — En- 
terolites — Volvulus — Internal  Strangulation. 

XXIL     HERNIA  59S 

Its  Causes,  Frequency  and  Varieties — Irreducible  Hernia — 
Strangulated  Hernia — Diaphragmatic  Hernia — Ventral  Hernia 
— Umbilical  Hernia — Inguinal  Hernia — Femoral  Hernia — Lum- 
bar Hernia — Vaginal  Hernia — Traumatic  and  Post-Operative 
and  Relapsed   Hernije. 

XXIII.    THE  RECTUM  AND  ANUS 618 

Anatomy — Alalformations  of  the  Rectum  and  Imperforate  Anus 
— Prolapsus  of  the  Rectum — Nevus  of  the  Rectum — Polypus  of 
the  Rectum — Bilharzia  Adenomata  of  the  Rectum — Proctitis — 
Syphilis  of  the  Rectum  and  Anus — Vegetations  or  Warts  about 
the  Anus — Fistula  in  Ano — Fissure  of  the  Anus — Hemorrhoids 
— Ischio-Rectal  Abscess — Marginal  Abscess. 


i8  CONTENTS 

CHAPTER  PAGE 

XXIV.  THE  GENITO-URINARY  ORGANS  .  .  .  .647 
Normal  Anatomy  and  Malformations  of  the  Kidneys — Float- 
ing Kidney—Injuries  of  the  Kidney — Renal  Calculus — Tubercu- 
lar Nephritis — Tumors  of  the  Kidney — Extroversion  and 
Tumors  of  the  Bladder — Foreign  Body  in  the  Urethra  or  in  the 
Bladder — Rupture  of  the  Urethra — Epispadias — Hypospadias — 
Adherent  Prepuce — Paraphimosis — Dislocation  of  the  Penis — 
Balanitis — Urethritis — Undescended  Testis — Misplaced  and  Hid- 
den Testis — Supernumerary  Testis — Tumors  of  the  Testis — 
Orchitis — Torsion  of  the  Spermatic  Cord — Varicocele — Tubercu- 
losis of  the  Testicle  and  of  the  Epididymis — Syphilitic  Tes- 
titis — Hydrocele  in  the  Male — Cyst  of  the  Spermatic  Cord — 
Misplacement   of  the   Ovaries — Ovarian  Tumors — Adhesion   of 

the  Labia  Minora — Adhesion  of  the  Clitoris  and  its  Prepuce — 
Prolapse  of  the  Female  Urethra — Vulvitis — Vulvo- Vaginitis, 
Simple  and  Specific. 

XXV.  HARE-LIP,     CLEFT-PALATE,     AND     THE     MOUTH, 

TONGUE,    FACE   AND    NECK 701 

Hare-Lip  and  Cleft-Palate — Macrostoma — Microstoma  and 
Atresia  Oris — Congenital  Absence  or  Malformation  of  the 
Tongue — Macroglossia — Papilloma,  Nevus  and  Fibroma  of  the 
Tongue — Cysts  Beneath  the  Tongue — Tongue  Tie — Epulis — • 
Supernumerary  Auricles  and  Branchial  Fistulae — Coloboma  of 
the  Eyelid — Epicanthus. 

XXVI.  CLUBFOOT    AND    SOME    OTHER    DEFORMITIES 

OF   THE   EXTREMITIES 722 

Clubfoot — Weak  Ankles — Clubhand — Supernumerary  Arms  or 
Legs,  Hands  or  Feet — Supernumerary  Digits  (Polydactylism) 
— Intra-Uterine  Amputations  and  Constrictions  and  Suppres- 
sion of  Intermediate  Parts — Absence  of  Parts — Webbed 
Fingers  or  Toes  (Syndactylism) — Irregular  Alignment  of  Digits 
— Malformations  of  Joints. 

APPENDIX 747 

[NDEX 763 


ILLUSTRATIONS 

FIG.  PAGE 

1.  Myxo-fibroma  of  rectum  66 

2.  Sarcoma  of  upper  end  of  humerus  72 

3.  Fibrocystic    sarcoma    "^t, 

4.  Fibrocystic   sarcoma.     Two   years   after   operation 73 

5.  Fibrocystic  sarcoma  removed  from  boy  74 

6.  Parasitic  fetus  attached  to  head  of  the  autosite  'j'j 

7.  Dermoid  cyst  near  the  orbit  79 

8.  Dermoid  of  testicle   81 

9.  Dermoid  of  ovary  82 

10.  Cavernous   nevus    84 

11.  Nevus  of  hand,  ulcerating  85 

12.  Nevus  of  lip   86 

13.  Lymphangioma   or   hygroma    88 

14.  Congenital  tumor   90 

15.  Cyst  of  the  socia  parotidis    92 

16.  Hydroperinephrosis    following    traumatism     93 

17.  Hydroperinephrosis  following  traumatism  after  operation 93 

18.  Hemophiliac  brothers   97 

19.  Hemophiliac   boy    98 

20.  21.     Rachitic  teeth  102 

22.  Typical  teeth  of  hereditary  syphilis   103 

23.  Rachitis    104 

24.  Typical    rachitis    106 

25.  Characteristic   attitude   of   rachitic   child    107 

26.  Beading  of  the  ribs  from  rachitis  108 

27.  28.     Hereditary  syphilis.     Destruction  of  nasal  bones  119 

29.  Hereditary   syphilis    120 

30.  Hutchinson  teeth    121 

31.  Head  of  infant  with  septic  inflammation  140 

32.  Tetanus     I43 

33.  Carbolic  acid  gangrene  149 

34.  Cancrum  oris  152 

35.  Cancrum  oris  in  a  Chinese  child   IS3 

36.  Burn  of  the  feet  caused  by  hot-water  bottle 155 

2)7-     Pseudohypertrophic    muscular    paralysis 164 

38.  Sheaths  of  the  flexor  tendons  of  the  hand  and  forearm 168 

39.  Hibbs-Sporon  method  of  tendon  lengthening 169 

40.  Anderson's  method  of  tendon  lengthening  170 

41.  Poncet's   method   of   tendon   lengthening    171 

42.  Method  of  introducing  silk  to  act  as  tendon 172 

19 


20  ILLUSTRATIONS 

FIG.  PAGE 

43.  Method  of  shortening  tendons  by  looping 174 

44.  Three  methods  of  tendon  shortening  174 

45.  Different  methods  of  tendon  transplantation    175 

46.  Different  ways  of  introducing  sutures  into  tendons   176 

47.  Suter's  method  of  uniting  the  ends  of  tendons   177 

48.  Various  methods  of  suturing  tendons  178 

49.  Radiograph  of  knock-knee   182 

50.  Plain  knock-knee  brace   184 

51.  52.     Case  of  knock-knee  before  and  after  correction    186 

53.     Case  of  genu  valgum    187 

54>     55-     Case  of  genu  valgum  showing  result  of  osteotomy 188 

56.  Long  single  bar  bow-leg  brace    190 

57.  Boston  Children's  Hospital  bow-leg  brace  190 

58.  59.     Bow-legs.     Before  and  after  osteotomy  191 

60.  Bow-legs.     Same  case  as  Fig.  58,  six  years  after  operation 192 

61,  62.  Knock-knee.     Before  and  after  correction 193 

63A,  B.     Rachitic  knock-knee  and  bow-leg.     Before  and  after  correc- 
tion      194 

64-67.     Case    of    bow-legs.      Skiagraphs    before    and    after    correction. 

Photograph  after  correction  195 

68.  Periostitis  and  osteitis  of  a  mild  type  200 

69.  Plastic   osteochondrosis    212 

70.  71.     Post-scarlatinal  poly-articular  arthritis   217 

72.     Rheumatoid    arthritis 221 

"JZ-     Semi-diagrammatic  section  through   right  shoulder  joint    226 

74.  Vertical  section  through  elbow  joint   226 

75.  Semi-diagrammatic  section  through  left  hip  joint  226 

76.  Section  through  left  knee  joint   226 

TJ.     Semi-diagrammatic  section  through  ankle  joint   227 

78.  Morbus  coxse.     First  stages    238 

79.  Diagram  representing  the  lower  extremity  fixed  in  abduction 240 

80.  Diagram  illustrating  tilting  of  pelvis   240 

81.  Diagram  illustrating  lower  extremity  fixed  in  adduction 240 

82.  Diagram  illustrating  tilting  of  pelvis  when  walking 240 

83.  84.     Thomas'    hip    splint 247 

85.  Ridlon's  modification  of  Thomas'  hip  splint 249 

86.  Hospital   long   splint    249 

87.  Phelps'  hip  crutch  and  fixation  splint   250 

88.  Ridlon's  traction  hip  splint  250 

89.  Tuberculosis^  of  knee-joint   256 

90.  91.     Tuberculosis  of  knee-joint  after  reduction  and  cured  258 

92.  Splint  for  gradual  extension  of  knee  or  elbow  259 

93.  Tuberculous    dactylitis    267 

94.  Tuberculosis  of  phalangeal  and  metatarsal  bones  268 

95.  Tuberculosis   of  metatarsal  bones    269 

96.  Tuberculous    osteo-chondritis    of    ribs    270 

97.  Radiograph  of  fracture  of  radius  and  ulna  272 

98.  Greenstick  fracture  of  radius  and  ulna 277 


ILLUSTRATIONS  21 

FIG.  PAGE 

99.     Greenstick  fracture  of  both  bones  of  forearm  277 

100.     Fracture  of  right  humerus  above  the  condyles   284 

loi.     Retardation  of  growth  in  length  of  radius   291 

102.  Radiograph  of  compound  fracture  of  tibia  and  fibula   296 

103.  Laxness    of  joints   in   childhood 299 

104.  Abnormal  laxness  of  joints  in  many  children 300 

105.  106.     Congenital  dislocation,  both  hips.     Front  and  side  view  ....  301 

107A,  B.     Congenital  dislocation,  one  hip.     Side  and  back  view   302 

108,  109.     Hibbs'  apparatus  for  reducing  congenital    dislocation   of 

hips.     View  from  above  and  side    306 

no.     First  step  of  operation  for  reducing  dislocation  of  hips    307 

III,     112.     Second  and  third  steps  of  same  operation  308 

113,     114.     Congenital  dislocation  of  hip,  after  reduction 309 

115.  Congenitally  dislocated  hip,  after  reduction  310 

116.  Hyperextension   of  the   knee 312 

117.  Congenital    dislocation   of   shoulder   with    normal   joint   for   com- 

parison         313 

118.  Congenital   dislocation  of  shoulder,  with  joint  laid  open    313 

119.  120.     Incomplete  dislocation  of  both  bones  of  forearm,  radio- 

graph          315 

121.  Showing  natural  creases  of  skin  upon  the  neck  334 

122,  123.     Hodgkin's   disease    337-338 

124.  Cephalhematoma     346 

125.  Hydrocephalus    internus     349 

126.  Fetal    hydrocephalus    350 

127.  Typical   chronic  hydrocephalus   in   infancy    351 

128.  Autopsy  on  case  of  chronic  internal  hydrocephalus  358 

129.  Ballance's  operation  for  hydrocephalus  internus  359 

130-  Chiene's  lines  marked  upon  scalp  of  child   360 

131-133-     Cranio-cerebral  topography    361,   362,  363 

I34j  135-     Malformation    of    ear,    jaw,    and    mouth.      Front    and    side 

view 37c 

136.  Line  of  incision  of  the  membrane  tympani   380 

137.  Paralysis   from   poliomyelitis    400 

138.  139.     Paralysis    from   poliomyelitis,    with   braces    applied    401 

140.  Weak-ankle   brace    402 

141.  Poliomyelitis    in   infancy    403 

142.  Hammer-toe  approximating  pes  cavus  404 

143.  Diagrams  showing  various  methods  of  nerve  suture   415 

144-146.     Spina    bifida     418,  421 

147.  Spinal   curvature   from  pseudohypertrophic   paralysis 425 

148.  Rachitic  spine    426 

149.  150.     Right  dorsal  rotary-lateral  curvature,  front  and  back 428 

151.  Boy   with   spinal   caries    < 436 

152.  Child   with  lower  dorsal   caries    437 

153.  Caries   of  the   spine    438 

154.  Dorso-lumbar  caries    439 

155.  Beginning   of   dorso-lumbar   caries    ,...  4^0 


22  ILLUSTRATIONS 

FIG.  PAGE 

156.  Typical  dorsal  caries,  and  also  hip-joint  disease  441 

157.  Leather   jacket   for    spinal    caries    444 

158.  Washburne's  brace   for    Pott's   disease    446 

159.  Spinal    brace   with    head    support    447 

160.  Leather  collar  for  caries  of  cervical  spine  448 

161.  162.     Effects  upon  the  face  and  figure  of  obstruction  of  the  upper 

air  passages  by  hypertrophy  of  tissues  of  the  naso-pharynx     455 
163,     164.     Gottstein's  and  Kirstein's  adenoid  curettes 457 

165.  Doyen's    forceps    457 

166,  167.     McKenzie's    and    Baginsky's    plain    tonsillotomes    464 

168.     Mason's  mouth  gag  465 

169, 
170, 
171 
172 

173 
174, 

175 


Stoerck's    tonsil    hemostat 466 

Tuberculosis  of  lymphatic  glands  of  the  neck  475 

Specimen  of  diphtheritic  membrane    489 

Set  of   O'Dwyer's   intubation  instruments    495 

"  Built  up  "  tubes  useful  for  granulation  tissue  496 

Foreign  body  tube  and  introducer  497 

Introducer  with  tube,  threaded    , 497 

176,    177.     The  extractor  and  mouth  gag 497,  498 

178a,   179a.     Renault's  method  of  extubation   503 

i8oa,  i8ia.     Marfan's  method  of  extubation   503 

178.  Deformity  of  thorax  from  rachitis   513 

179.  Rickety  deformity  of  the  thorax   514 

180.  "  Funnel  chest  "    51S 

181.  182.     Empyema.     Distension  of  thorax  and  obliteration  of  spaces  517 
183,    184.     Empyema.     Left  side,  with  displacement  of  heart 518 

185.  Encysted  empyema,  with  adjacent  portion  of  lung  consolidated  ...  519 

186.  Whooping  cough,  measles,  and  pneumonia  with  empyema 523 

187.  Flint's  empyema  drainage  tubes   526 

188.  189.     After  excision  of  rib  for  drainage  of  empyema 527,  528 

190.  Tuberculosis  and  bronchitis  following  measles   570 

191.  Vertical  section  of  an  intussusception   573 

192.  193.     Double  and  triple  invagination  of  intestine    573 

194.  Specimen  of  ileo-colic  intussusception   574 

195.  Eliot's  suggestion  for  relief  of  intussusception   590 

196-198.     Excision  of  intussusceptum  591 

199.  Case   of   congenital   diaphragmatic   hernia    602 

200.  Lungs,  pericardium,  etc.,  in  case  of  diaphragmatic  hernia 602 

201.  Kelley's  truss  for  umbilical  hernia    605 

202.  Kelley's  truss  for  umbilical  hernia  applied    606 

203-205.     Congenital  inguinal,  funicular,  and  infantile  hernia 607 

206,     207.     Encysted  and  acquired  inguinal  hernia  608 

208.  Hernia  in   the  canal  of  Nuck 608 

209,  210.     Double  scrotal  hernia,  before  and  after  operation  609 

211,     212.     Indirect  inguinal  hernia,  before  and  after  operation  610 

213.     Traumatic  orchitis  and  strangulated  and  imperforate  hernia 611 

214-222.     Malformations  of  the  rectum  and  imperforate  anus 622 

223.     Imperforate  anus 623 


ILLUSTRATIONS                                         '  23 

FIG.  PAGE 

224.  Malformation  of  the  rectum ,.0  .......  „  631 

225.  Malformed  bowel  from  case  shown  in  Fig.  224 632 

226.  Sarcoma  of  kidney 660 

2.2J.     Sarcoma  and  kidney  of  case  shown  in  Fig.  226  661 

228.  Extroversion  of  the  bladder  and  right  inguinal  hernia    664 

229,  230.     Wood's  operation  for  extroversion  of  the  bladder 665,  666 

231.  Segond's  operation  for  extroversion  of  the  bladder 667 

232.  Result    after  operation  for   ectopia   vesicae 66g 

233.  Thiersch's  and  Duplay's  operations 678 

234.  Paraphimosis 684 

235.  Double  congenital   hydrocele  and  umbilical   hernia 692 

236-238.     Congenital,  funicular  and  infantile  hydrocele   693 

239-241.     Hydrocele   of  the   cord,   of   the   tunica   vaginalis   and   of   the 

canal  of  Nuck , o ....... .  693 

242.  Cyst  of  the  spermatic  cord 695 

243.  Adhesion  of  the  labia  minora   697 

244.  Mouth  of  an  embryon  of  forty  days 702 

245.  246.     Hare-lip  with  wide  cleft,  before  and  after  operation 703 

247.  Hare-lip   shown   for  comparison 7^4 

248,  249.     Hare-lip,   before   and    after   operation 705 

250-252.     Severe  cases  of  hare-lip  and  cleft-palate,  before  and  after 

operations    707 

253-264.     Illustrate  operations  for  double  and  single  hare-lip..     710,  Til 

265,    266.     Urano    staphylorrhaphy 713,  714 

267-269.     Hare-lip  and  wide  cleft  of  hard  and   soft  palate     715,    716,  717 
270-272.     Talipes  varus.     Before  and  after  treatment  by  tenotomies   . . .  723 
273-275.     Talipes    equino-varus,    before    and   after    treatment    by   tenot- 
omies   and    plaster    bandages. 724 

276.     Pes   planus   or   flat   foot 725 

'^77 1     278.     Double  talipes  varus,  anterior  and  posterior  view   726 

279.  Same  case  as  Figs.  277  and  278,  after  treatment.............  72^ 

280.  Talipes  equino-varus 728 

281.  Double  talipes  equino-varus 729 

282.  283.     Same  case  as  Fig.  280,  after  correction 730 

284.  Same  as  Fig.  280,  after  tenotomy  and  use  of  plaster  bandages.  ..  .  731 

285.  Retention  brace  for  clubfoot  732 

286.  Walking  shoes  for  double  clubfoot 732 

287.  Author's  metallic  fulcrum 7ZZ 

288.  Clubfoot   wrenches    TZZ 

289.  Two  pairs  of  feet,  each  pair  has  one  foot  paralyzed  and  the  other 

somewhat  flattened  from  extra  weight-bearing 735 

290.  Weak  ankles  and  talipes  valgus 739 

29T,     292.     Supernumerary  fingers 740,  741 

293.  Supernumerary  toes   74^ 

294.  Malformation  of  left  hand  743 

295.  Abnormal  alignment  of  the  toes 743 


REFERENCES    TO     THE    APPENDIX 

are  indicated  in  the  text  by  black  face  num- 
erals in  parentheses.    Appendix  starts  page  747. 


CHAPTER  I 

EXAMINATION,     CASE-TAKING    AND     GENERAL 
SUBJECTS 

Examining  and  Case- Taking — Anesthetics — Asepsis  and  Anti- 
sepsis— Bandaging,  Dressing  and  the  Application  of 
Splints — Hemorrhage  and  Its  Control — Shock — After 
Operation — Lavage,  Gavage  and  Rectal  Feeding — Anat- 
omy, Growth,  and  Development. 

EXAMINING  AND   CASE-TAKING 

There  should  be  children's  surgeons  as  well  as  children's  physi- 
cians;  or,  "if  one  objects  to  cutting  up  surgery  into  little  pieces," 
as  Timothy  Holmes  says,  it  should  at  least  be  required  that  the 
surgeon  extend  his  knowledge  to  pediatrics.  Thus  only  can  he  be 
qualified  to  practice  successfully  among  children.  Moreover,  he 
should  possess  in  eminent  degree,  sympathy,  tact,  patience,  firm- 
ness, and  gentleness  in  dealing  with  his  little  patients.  His  observ- 
ing  and  reasoning  powers  should  be  of  the  keenest,  for  often  all 
depends  upon  the  objective  signs  and  symptoms,  the  patient  lending 
no  aid.  In  examining  and  in  operating,  his  touch  should  be  accu- 
rate and  delicate,  for  the  tissues  of  the  young  are  softer  and  more 
frail,  and  the  structures  and  spaces  smaller  than  in  the  grown-up. 

The  temptation  to  hasty  and  superficial  examination  of  cases 
incident  to  all  lines  of  practice  are  greatly  increased  in  the  cases  of 
infants  and  children,  whose  speechlessness,  fright,  unruliness,  lack 
of  comprehension  and  compliance,  and  natural  restlessness,  together 
with  the  numerous  peculiarities  of  their  disorders,  render  the  task 
so  difficult  and  tedious  that  one  is  tempted  to  end  the  interview  by 
making  a  guess  at  the  condition.  But  if  the  surgeon  be  possessed 
of  the  proper  qualifications  and  trained  in  his  art,  he  can  almost 
invariably  proceed  step  by  step  unfailingly  to  secure  the  necessary 
information  and  complete  his  examination  and  diagnosis.  Again, 
the  novice  in  pediatrics,  witnessing  the  facility  with  which  the 
experienced  practitioner  proceeds  to  his  examination  with  well- 
directed  questions  and  deft  touches,  and  goes  straight  to  a  diagnosis 
which  proves  to  be  the  correct  one,  is  apt  to  imagine  that  anyone 
can  easily  do  the  same.  He  fails  to  recognize  that  what  seems  like 
divination  is  the  result  of  knowledge,  and  of  skill  acquired  by  innu- 


26  SURGICAL   DISEASES    OF   CHILDREN 

merable  careful  systematic  examinations  and  long  experience ;  and 
he  does  not  realize  that  the  examiner  makes  many  observations  with 
his  eyes  and  ears  and  with  his  senses  of  touch  and  smell  and  tem- 
perature, and  performs  a  numerous  series  of  reasoning  processes 
during  the  time  that  he  appears  to  be  only  chatting  with  the  mother 
or  playing  with  the  child  before  performing  any  ostensible  exam- 
ination. It  will  not  be  necessary  in  every  case  to  make  a  complete 
record  by  all  the  means  described  below,  but  it  is  advised  that  the 
student  of  pediatric  surgery  make  a  systematic  examination  of 
each  case  before  he  ventures  upon  diagnosis  and  treatment. 

In  emergency  of  injury  or  disease  the  surgeon  may  come 
directly  to  the  special  or  local  examination  of  the  wounded  or 
affected  parts  and  proceed  at  once  to  apply  the  appropriate  treat- 
ment, reserving  until  afterward  the  systematic  survey  of  the 
patient's  history  and  health  conditions  when  such  may  have  an 
influence  on  the  case.  But  in  most  cases  it  is  better  to  proceed 
methodically  and  elicit  the  history  in  chronological  order  and  logical 
sequence.  I  have  small  respect  for  the  judgment  of  a  surgeon  who 
fears  to  hear  the  history  before  he  examines  the  case,  lest  his  opin- 
ion be  prejudiced.  It  is  especially  desirable  in  the  case  of  a  child 
that  the  history  be  heard  first,  so  that  the  examination  can  be 
rightly  directed  and  an  injured  or  painful  point  not  unexpectedly 
encountered,  or  an  exploration  not  unnecessarily  repeated.  In  an- 
swering questions  upon  the  history,  while  the  patients  themselves 
do  not,  as  is  sometimes  the  case  with  adult  patients,  try  to  deceive 
the  surgeon,  parents  or  guardians  often  make  misstatements — either 
unintentionally  through  ignorance,  or  intentionally,  when  by  doing 
so  they  may  hide  their  own  carelessness  or  negligence.  It  is  some- 
times better  to  hear  the  history  in  the  absence  of  the  patient,  or 
while  he  is  asleep,  during  which  he  should  be  inspected,  and  per- 
haps also  handled.  If  a  written  record  of  the  case  is  to  be  made, 
the  date  will  of  course  be  noted,  then  the  name  of  the  patient,  fol- 
lowing which  should  appear  the  name  and  address  of  parent  or 
guardian.  The  age  of  the  child  should  be  recorded,  and  if  it  be 
under  four  years  the  fractions  of  a  year  should  also  be  indicated ; 
if  under  two  and  a  half  years  the  fractions  should  be  expressed  in 
months.  In  the  rapidly  changing  conditions  of  early  life  a  few 
months,  and  in  the  new-born  babe  even  a  few  days  or  hours,  make 
a  great  difference  in  the  disorder  that  is  likely  to  be  present,  or  in 
the  result  of  an  injury,  or  lin  the  advisability  of  an  operation  and  in 
the  probable  outcome  of  the  case.  Consider,  for  instance,  an  intra- 
cranial hemorrhage,  or  a  fracture,  or  an  imperforate  anus,  or  a 
cleft  palate. 

Sex  should  be  noted  in  the  case  record ;  although,  aside  from 
the  malformations  of  the  genito-urinarv  organs,  the  surgical  dis- 


EXAMINATION,    CASE-TAKING    AND    GENERAL    SUBJECTS    27 

eases  of  the  sexes  are  not  so  widely  differentiated  as  in  the  adult. 
Young  boys  and  girls  are  very  much  alike  as  to  their  ailments, 
as  they  are  also  similar  in  the  characteristics  of  mind  and  disposition, 
which  so  widely  vary  in  men  and  women.  Still,  little  girls  more 
often  have  gonorrheal  vaginitis  than  little  boys  have  specific  ure- 
thritis ;  and  boys  show  hemophilia,  while  girls  do  not ;  and  more 
boy  babies  than  girl  babies  are  injured  in  the  act  of  birth,  and  so  on. 
With  a  little  more  age  the  differences  in  psychical,  as  well  as  physi- 
cal, endowment,  and  consequently  in  habits  and  occupation  begin 
to  manifest  themselves.  For  instance,  we  find  the  boy  more  often 
daring  exposure  and  contracting  empyema,  while,  on  account  of 
muscular  weakness  and  more  sedentary  games  and  employments, 
more  girls  than  boys  have  lateral  curvature  of  the  spine.  Fortu- 
nately, aside  from  school  life,  which  oftentimes  is  trying  enough, 
occupation  has  seldom  had  opportunity  to  leave  its  brand  upon 
the  body  of  the  growing  child. 

Race  or  nationality  should  be  noted,  for,  while  no  race  or 
nation  is  absolutely  prone  or  immune  to  any  disease  to  which  the 
species  is  heir,  it  is  often  extremely  interesting  to  trace  the  effects 
of  race,  and  of  climate,  food,  dress,  and  manner  of  life  in  producing 
or  favoring  diseases  or  injuries :  for  instance,  the  prevalence  of 
rickets  among  Italians  and  Negroes. 

If  the  case  is  one  of  disease,  it  increases  the  importance  of 
inquiring  into  the  family  history.  This  inquiry,  without  offending 
or  arousing  the  suspicions  of  the  parent,  should  disclose  any  prob- 
ability of  syphilis,  or  of  hemophilia,  and  even  family  tendencies  to 
rheumatism,  to  neuroses,  to  tumor-growth.  Although  we  now  think 
that  tuberculosis  is  but  very  rarely  directly  inherited,  a  predisposi- 
tion to  that  disease  may  be  a  heritage ;  moreover,  its  presence  in 
a  family  or  in  a  habitation  increases  the  chances  for  infection,  so 
that  the  question  of  tuberculosis  should  always  be  inquired  into. 
Coming  now  to  the  personal  history,  one  would  like  to  know 
whether  the  child  was  born  at  full  term,  whether  there  was  any 
difficulty,  accident,  or  injury  at  the  birth,  or  any  infection  or  inflam- 
mation following  the  birth.  Then  whether  the  babe  was  breast  fed 
or  artificially  fed,  and  if  the  latter,  what  was  the  food.  What,  if 
any,  illness  or  injury  previous  to  the  present  has  the  patient  sus- 
tained. Answers  to  these  questions  may  only  serve  to  estimate  the 
resistance  to  disease  or  the  recuperative  power,  or  an  injury  or  dis- 
ease may  be  the  direct,  the  indirect,  or  the  predisposing  cause  to 
the  present  trouble. 

In  taking  the  history  of  the  present  trouble  it  is  well  to  fix  the 
date  of  the  onset  as  accurately  as  possible.  Upon  this  point  mis- 
statements are  particularly  apt  to  occur.  Sometimes  these  are  readily 
detected,  as  when  a  mother  declares  that  a  pigeon-breast  or  a  spinal 


28  SURGICAL   DISEASES    OF   CHILDREN 

curvature  came  since  last  week's  bath;  but  often  one  would  very 
much  like  to  know  truly  when  a  boy  began  to  limp,  or  when  a  tumor 
first  appeared,  or  when  it  first  began  to  grow  rapidly,  or  when  the 
attack  of  poliomyelitis  took  place.  Questions  as  to  the  acquired  vices 
are  very  seldom  appropriate  upon  the  list  for  the  young  subject,  yet 
one  should  not  forget  that  frequently  there  are  vices  of  feeding,  and 
of  the  abuse  of  drugs  and  patent-medicines,  and  of  tea  and  coffee, 
and  even  of  alcohol. 

As  to  the  personal  examination  of  an  infant  or  a  child, 
although  the  surgeon  should  have  a  methodical  plan,  it  by  no  means 
follows  that  he  can  take  the  steps  of  his  examination  in  the  order 
he  had  planned.  He  should  be  prepared  to  begin  at  either  end  or 
any  place  in  his  list,  or  to  vary  his  program  instantly,  according  to 
the  behavior  of  the  patient ;  to  interrupt  any  procedure  at  any  point 
in  order  to  make  some  other  observation  when  the  opportunity 
offers.  But  returning,  he  should  continue  with  persistent  patience 
until  a  satisfactory  knowledge  is  secured.  A  child  should  always 
be  stripped  for  examination,  and  this  should  be  in  a  comfortably 
warm  room.  Exposure  to  cold  is  not  only  unpleasant  and  possi- 
bly injurious,  but  moderate  cold  increases  the  muscular  tonicity  and 
quickens  the  reflexes  so  as  to  be  deceptive.  If  possible,  observe  the 
child  while  he  is  at  play,  as  his  instinctive  attitudes  and  spontaneous 
movements,  as  well  as  his  voluntary  complaints,  are  more  instruct- 
ive than  those  elicited  by  the  examiner.  Hasten  slowly.  Nothing 
is  to  be  gained  and  everything  may  be  lost  by  haste  or  abruptness 
in  the  examination  of  a  child.  I  have  often  noticed  a  child  more 
obedient  to  signs  than  to  words  of  command.  He  will  understand 
pantomime  more  readily  than  language.  For  instance,  you  hold 
out  your  arms  and  he  will  comiC  to  you,  but  if  you  say  "  Come  to 
me,"  he  will  turn  the  other  way.  It  seems  as  if  he  regards  your 
presence  and  your  voice  as  two  distinct  causes  of  alarm,  and  it  will 
take  him  twice  as  long  to  get  used  to  both  of  them.  Once  fix  the 
child's  attention,  and  then  be  careful  not  to  startle  him,  and  he  will 
obey  you  almost  like  the  hypnotic  subject.  With  older  children  one 
can  accomplish  something  by  talk,  but  even  with  them  one  should 
not  talk  too  much  about  what  he  is  doing  or  going  to  do,  but  chat 
about  anything  else — toys,  games,  school — while  going  on  with  the 
examination.  Begin  with  the  simple  steps  of  the  examination  and 
come  to  the  more  difficult  or  alarming  later.  Children  vary  greatly 
as  to  fear  and  as  to  the  endurance  of  pain  under  examination.  It  is 
wrong  to  prolong  an  examination  painfully  for  the  sake  of  elicit- 
ing the  last  iota  of  information  unless  the  case  turns  on  that  last 
fact.  But  if  a  disagreeable  thing  should  be  done,  one  must  have 
the  firmness  to  do  it.  If  a  child  is  altogether  vicious  and  intract- 
able, it  is  useless  to  waste  time  in  coaxing — complete  the  examinct- 


EXAMINATION,    CASE-TAKING    AND    GENERAL    SUBJECTS    29 

tion  at  once.  It  never  pays  to  deceive  a  child  by  telling  him  that 
it  is  not  going  to  hurt  when  the  next  moment  gives  you  the  lie. 
One  may  thus  succeed  for  the  moment,  but  the  child's  confidence 
is  lost  and  was  worth  infinitely  more.  Better  tell  him  it  may  hurt 
a  little,  but  not  more  than  he  can  stand,  and  you  may  be  astonished 
at  his  fortitude.  I  have  many  times  remarked  upon  the  fortitude 
with  which  a  child  would  bear  severe  pain,  such  as  the  placing  of 
skin  sutures  or  the  reduction  of  a  fracture  or  dislocation,  when  an 
anesthetic  was  inadvisable  or  not  at  hand.  A  general  anesthetic 
should  usually  be  given  for  thorough  examination  of  painful  or 
difficult  cases,  such  as  obscure  joint  injuries,  severe  burns,  suspected 
intussusception,  sounding  the  bladder,  and  the  like.  Sometimes  the 
anesthetic  is  necessary  for  muscular  relaxation,  as  in  searching  for 
tumor  in  suspected  intussusception,  or  other  abdominal  tumor,  or 
differentiating  between  muscular  spasm  and  true  ankylosis  of  a 
joint.  Children  do  not  relax  the  muscles  upon  request.  They  may 
if  the  attention  is  diverted,  unless  the  muscle  is  spastic. 

The  child's  height,  weight,  and  degree  of  growth  and  develop- 
ment in  proportion  to  its  age  should  be  observed.  Also  the  state 
of  its  nutrition,  the  appearance  of  pallor,  puffiness  or  edema,  cya- 
nosis, icterus,  or  skin  eruption,  cicatrices,  ulcers,  or  discolorations. 
Observe  the  hair  and  scalp.  Notice  the  size  of  the  head  and  its 
relative  size.  At  birth  it  should  exceed  in  size  the  thorax,  and 
not  until  between  the  second  and  third  year  does  the  thorax  exceed 
the  head  in  size.  If  the  head  is  too  small,  one  seeks  for  micro- 
cephaly; and  if  too  large,  for  rachitis  or  hydrocephalus.  Observe 
the  chest — its  size  and  shape  and  respiratory  movements.  Look  for 
bulging  or  retraction  of  the  intercostal  spaces,  for  failure  of  expan- 
sion, or  for  distension  of  one  side  or  region ;  for  beaded  ribs,  or 
Harrison's  groove,  or  the  asymmetry  of  spinal  curvature,  or  rickety 
deformity.  Observe  the  countenance,  with  its  play  of  expression, 
its  look  of  transient  pain  or  of  continued  suffering,  of  tetanic  rigid- 
ity, of  mental  alertness  or  dullness,  or  apathy  or  vacuity.  .  Observe 
the  special  senses  and  speech,  the  teeth,  tongue,  throat,  and  nares. 
The  lymphatic  glands  should  be  sought  by  palpation,  and,  if  palpa- 
ble, the  cause  sought.  The  heart  and  lungs,  the  liver  and  spleen, 
the  abdomen  and  its  organs,  the  hernial  regions,  the  bladder  and 
genitalia  should  each  receive  attention.  The  feces  and  urine  may 
need  inspection,  or,  like  the  morbid  discharges  of  wounds,  sinuses, 
the  throat,  genital  organs,  or  skin  lesions,  or  the  blood  itself  require 
laboratory  investigation.  Too  little  attention  is  usually  paid  by  the 
surgeon  to  the  general  condition  of  the  child,  the  stage  of  its  devel- 
opment, the  state  of  its  nutrition,  and  the  condition  of  the  other 
organs  or  systems  than  the  one  particularly  affected ;  and  even  the 
afflicted  member  is  too  often  looked  upon  as  a  mechanical  prob- 


30  SURGICAL   DISEASES    OF   CHILDREN 

lem — a  field  for  the  exercise  of  mechanical  dexterity,  operative  tech- 
nique, or  as  material  for  the  testing  of  a  favorite  apparatus.  A 
systematic  examination  of  the  patient  will  not  only  enable  one  to 
"  take  stock "  of  the  organism  as  a  whole,  but  may  lead  him  to 
important  discoveries  of  underlying  conditions  or  of  complications 
which  would  otherwise  be  overlooked.  Complications  are  not  so 
frequent  in  young  subjects  as  in  older,  but  they  do  sometimes  occur; 
while  it  is  certain  that  constitutional  vices  and  chronic  diseases  are 
sometimes  entirely  ignored,  the  attention  of  the  examiner  being 
entirely  taken  up  with  a  recent  injury  or  a  local  manifestation  of 
disease. 

The  extremities  should  be  carefully  examined  in  every  case  of 
acute  illness  in  children.  The  digestive  disturbances,  the  exanthe- 
mata and  respiratory  inflammations  are  so  common  that  one's  atten- 
tion is  apt  to  be  drawn  away  from  an  acute  osteomyelitis,  or  peri- 
ostitis, or  synovitis.  The  instinctive  attitude  and  motor  state  of 
the  limbs  should  be  observed,  and  any  change  in  position,  motion, 
or  outline  noted.  The  hand  should  be  passed  over  each  extremity 
in  a  search  for  swelling  or  tenderness  or  heat,  and  the  action  of 
the  joints  should  be  tested. 

The  attitude  and  motor  state  are,  in  general,  more  reliable 
indices  in  the  child  than  in  the  adult,  and  in  the  infant  than  in  the 
older  child.  The  younger  the  young  patient  is,  the  less  are  the 
attitudes  and  motions  dictated  by  fashion,  altered  by  customary 
occupation,  influenced  by  habit  or  affectation,  or  assumed  with  the 
intention  of  deceiving.  They  may  be  modified  not  only  by  disease, 
but  by  bashfulness  or  fear.  The  attitudes  and  motions  of  a  well 
child  are  graceful  and  easy ;  conversely,  an  uncomfortable  or  re- 
strained or  a  constrained  or  awkward  movement  indicates  disease 
or  injury.  A  well  child  is  active  while  awake  and  rests  quietly 
while  asleep.  Conversely,  if  the  conditions  are  reversed  and  the 
child  becomes  inactive  while  awake  or  restless  during  sleep,  some- 
thing is  wrong  with  him.  Muscles  may  be  tense  merely  from  cold, 
or  from  fright  and  struggling,  or  from  pain,  spastic  contracture, 
or  reflex  irritation.  General  muscular  relaxation  comes  from 
extreme  prostration  or  brain  disease.  When  a  child  which  has 
been  bed-ridden  for  some  time  begins  to  toss  about,  constantly 
changing  position  and  at  rest  nowhere,  it  is  a  semeion  of  evil.  Dress- 
ings should  be  examined  and  search  made  for  some  complication.  In 
croup  or  other  obstruction  in  the  air  passages  it  indicates  very  grave 
air  hunger.  If  there  has  been  hemorrhage  it  shows  extreme  anemia. 
In  all  cases  it  heralds  the  approach  of  nervous  exhaustion.  If  the 
child  lies  on  his  back  and  cries  whenever  touched  or  moved,  one 
thinks  of  pleuritis,  appendicitis,  peritonitis,  scurvy,  pseudo-paraly- 
sis, extreme  rickets,  synovitis.    But  it  might  be  a  distended  bladder 


EXAMINATION,    CASE-TAKING    AND    GENERAL    SUBJECTS    31 

or  hernia.  If  he  draws  up  his  legs  to  lash  out  again  and  twist  and 
turn  himself,  he  likely  has  irritation  and  pain,  but  not  inflammation. 
If  the  child  who  has  symptoms  of  pleuritis  and  has  been  lying  on 
the  affected  side,  turns  and  prefers  the  dorsal  decubitus,  one  will 
likely  find  a  large  effusion.  When  the  patient  with  empyema,  on 
whom  thoracotomy  or  resection  has  been  performed,  refuses  to  lie 
on  the  affected  side,  it  is  because  the  drainage  tube  is  too  long  or 
the  dressing  pads  about  it  not  properly  placed,  or  the  pillows  so 
arranged  that  the  wound  is  drawn  asunder.  Rigidity  of  the  cervi- 
cal muscles  occurs  with  caries  of  the  cervical  spine,  and  with  retro- 
pharyngeal abscess  and  rheumatic  torticollis  or  diphtheria.  The 
retraction  of  the  neck  accompanying  meningitis,  cerebellar  tumor, 
pneumonia,  or  typhoid  is  not  so  apt  to  be  confused.  With  opis- 
thotonos in  a  wounded  patient,  one  thinks  of  tetanus,  but  should 
bear  in  mind  the  possibility  of  meningitis  or  of  overdosing  with 
strychnine  or  nux  vomica.  Paralysis  of  cervical  muscles,  allowing 
the  head  to  loll  forward  on  the  breast,  is  seen  as  a  sequel  of  diph- 
theria. It  is  sometimes  difficult  to  distinguish  in  young  children 
between  paralysis  and  what  Fothergill  called  "  the  muscular  list- 
lessness  of  malnutrition."  And  care  is  necessary  in  differentiating 
between  true  paralysis,  the  pseudo-paralysis  of  scurvy,  and  the 
acute  epiphysitis  of  hereditary  syphilis.  One  has  seen  the  pseudo- 
paralysis of  scurvy  mistaken  for  acute  poliomyelitis,  and  syphilitic 
epiphysitis  mistaken  for  traumatic  separation  of  the  epiphysis.  If 
a  single  arm  of  a  new-born  infant  appears  paralyzed,  very  likely 
it  is  a  birth  palsy,  but  before  concluding  that  it  is  due  to  injury  of 
a  nerve  alone  it  is  well  to  examine  closely  for  fracture  of  a  clavi- 
cle or  separation  of  the  upper  epiphysis  of  the  humerus,  which  may 
either  simulate  paralysis  or  be  associated  with  it.  If  ari  older  child 
refuses  to  use  his  hand  or  forearm  and  we  find  nothing  wrong  with 
them,  we  may  discover  that  his  collar-bone  is  broken.  Or  he  will 
not  put  his  foot  to  the  floor,  and  after  a  while  it  is  found  that  he  has 
psoas  abscess,  pericecal  inflammation,  ureteral  calculus,  or  a  hernia. 
The  domain  of  the  nervous  diseases  connected  with  children's 
surgery  will  not  be  entered  upon  in  this  chapter.  The  attitude  and 
motor  state  characterizing  hip-joint  disease  and  diseases  simulating 
it,  of  tetany,  spinal  caries  and  curvatures,  the  various  fractures  and 
dislocations,  diseases  and  injuries  of  muscles,  bones  and  joints, 
limp  from  strain  or  old  fracture,  will  be  alluded  to  in  due  course. 
Enough  has  been  said  here  to  illustrate  the  necessity  of  careful 
examination  of  the  young  patient  and  somewhat  concerning  the 
manner  of  the  investigation.  Something  should  be  said  of  the  body 
temperature  and  our  respects  paid  to  the  overworked  clinical  ther- 
mometer. Temperature  is  an  important  symptom  and  should  be 
v^^atched.     But  its  variations  are  by  no  means  as  significant  in  the 


3^  SURGICAL   DISEASES    OF   CHILDREN 

case  of  a  child  as  of  an  adult.  Even  in  health  there  may  be  a  con- 
siderable daily  variation,  and  with  the  unstable  nervous  organization 
of  the  child,  very  slight  or  transient  causes,  such  as  indigestion, 
fright  or  anger,  will  send  the  mercury  up.  The  pulse,  too,  is  sub- 
ject to  frequent  changes  in  its  rate  from  passing  disturbances  which 
would  have  no  effect  upon  an  adult.  Respiration  to  a  less  degree 
exhibits  this  instability,  so  that  a  recorded  rise  or  fall  of  any  one  of 
these  should  be  considered  in  their  ratio,  one  with  the  others,  and 
in  conjunction  with  other  symptoms,  such  as  the  appetite,  the 
cheerfulness  and  comfort  of  the  patient,  sleep,  the  excretions  of 
bowels  and  kidneys,  condition  of  skin  and  tongue  and  throat,  the 
appearance  of  the  wound,  if  one  is  present.  If  all  is  well  otherwise, 
a  transient  fever  is  not  alarming. 

But  a  persistent  fever,  even  though  not  high,  is  something  to 
be  carefully  inquired  into  and  watched  with  suspicion,  and  investi- 
gated again  and  again  until  its  presence  is  explained.  Conversely 
the  absence  of  fever  is  no  proof  that  a  case  is  doing  well,  or  that 
a  wound  has  not  suppurated.  This,  says  Powers,  is  "  perhaps 
because,  as  the  young  tissues  are  more  elastic,  the  tension  is  less 
marked  and  there  is  less  septic  absorption."  And  perhaps  the  unre- 
liable, undeveloped  nervous  organization  sometimes  works  too  lit- 
tle, as  at  other  times  too  much.  However  explained,  one  has  often 
observed  the  fact. 

If  only  other  instruments  of  precision  were  as  convenient 
and  as  easy  of  application  as  the  thermometer  they  would  be 
more  popular — the  sphygmomanometer,  for  instance.  Although 
the  blood-pressure  is  not  often  a  matter  of  great  concern  in  pedi- 
atric surgery,  ;it  is  well  to  know  the  normal.  This  has  recently 
been  investigated  by  Stowell  (Arch.  Ped.,  Feb.,  1908)  by  obser- 
vations upon  216  patients.  He  concludes  that  vascular  tension 
is  lower  in  childhood  than  in  adult  life.  The  following  may 
be  taken  as  the  averages  in  health:  In  men,  from  100  to  145 
mm.;  in  women,  10  mm.  less;  in  infants  under  2  years  of  age, 
75  to  90  mm.;  3  years,  91  mm.;  4  years,  89  mm.;  5  years, 
95  mm.;  6  years,  96  mm.;  7  years,  102  mm.;  8  years,  loi  mm.; 
9  years,  102  mm.;  10  years,  112  mm.;  11  years,  102  mm.;  12  years, 
III  mm.;  13  years,  107  mm.;  14  years,  iio  mm.;  15  years,  109 
mm.;   16  years,  117  mm.;   17  years,   103  mm. 

The  aid  of  the  clinical  laboratory  must  often  be  sought,  and  the 
chemical,  microscopical,  and  bacteriological  findings  examined  be- 
fore one  arrives  at  his  final  diagnosis.  The  percentage  of  hemo- 
globin in  the  blood,  the  leucocyte  count,  the  differential  count,  and. 
the  iodine  test  for  glycogen  are  all  useful  and  valuable  when  con- 
sidered in  connection  with  the  other  symptoms  and  the  history  of 
the  case.    The  normal  amount  of  hemoglobin  is  comparatively  high 


EXAMINATION,    CASE-TAKING    AND    GENERAL    SUBJECTS     33 

in  the  new-born  babe,  being  above  loo.  It  falls  rapidly  for  a  few 
days  and  has  reached  lOO  by  the  second  week.  It  continues  to  fall 
for  about  two  months,  and  then  remains  rather  low  for  the  first 
two  years,  after  which  it  rises  until  about  puberty.  In  young  chil- 
dren the  average  is  from  85  as  the  high  to  65  as  the  low  limit. 

The  normal  total  number  of  leucocytes  per  cubic  millimeter 
is  larger  in  infancy  than  in  adult  life.  At  birth  they  number  12,000 
to  25,000.  They  diminish  rapidly  during  the  first  few  days,  reach- 
ing 9000  to  14,000.  The  general  average  during  childhood  is  from 
6000  to  12,000. 

The  presence  of  a  leucocytosis  is  evidence  of  an  inflamma- 
tion which  the  system  is  resisting.  It  should  always  be  searched 
for  in  a  case  suspected  of  being  an  inflammation  of  pyogenic  origin, 
such  as  septicemia,  appendicitis,  osteomyelitis,  peritonitis,  empy- 
ema, pyemia,  and  the  like. 

The  absence  of  a  leucocytosis  does  not  deny  the  possibility  of  the 
presence  of  an  inflammation,  or  even  of  pus,  for  either  the  system 
may  be  so  overpowerd  by  the  infection  or  so  debilitated  as  to  make 
no  resistance  of  this  kind  against  the  disease,  or  the  pus  may  have 
become  walled  off  so  that  no  further  absorption  is  taking  place  and 
the  leucocytosis  has  returned  to  the  normal.  If  the  leucocytosis  is 
progressively  increasing,  it  is  probable  that  suppuration  will  ensue, 
and  it  is  an  indication  for  prompt  operation  under  circumstances 
in  which  operation  should  forestall  suppuration,  for  instance,  in 
appendicitis. 

One  should  not,  however,  be  deceived  as  to  the  condition  by  a 
high  leucocyte  count,  for  this  may  mean  leukemia  and  not  leu- 
cocytosis, unless  the  number  of  polymorphonuclear  cells  is  also 
increased.  In  the  differential  count  of  the  polymorphonuclears  it 
should  be  borne  in  mind  that  the  normal  frequency  of  the  various 
forms  of  leucocytes  is  different  in  infancy  from  that  in  adult  life, 
as  may  be  seen  from  the  following  comparison : 

INFANT.  ADULT. 

Lymphocytes 40-60  20-30 

Large  mononuclears    4-12  4-8 

Polymorphonuclears    20-40  62-72 

Eosinophiles    2-4  ^-4 

Mast  cells  1/40-^ 

Leucocytosis  may  be  present  in  wasting  disease  which  is 
approaching  a  fatal  end,  this  cachectic  leucocytosis  being  either 
toxic  or  excited  by  terminal  infections.  Or  it  may  be  caused  by 
severe  hemorrhage  or  by  malignant  disease.  Moreover,  there  is 
a   transient   physiologic    leucocytosis    following   cold   bathing   and 


34  SURGICAL   DISEASES    OF    CHILDREN 

massage  and  ingestion  of  food.  There  are  a  number  of  acute  infec- 
tious diseases  in  which  leucocytosis  does  not  take  place — for 
instance,  measles,  malaria,  unmixed  tuberculosis,  mumps,  and 
typhoid.  Thus  the  presence  of  a  leucocytosis  may  help  to  decide 
whether  an  inflammation  is  tubercular  or  pyogenic,  or  whether  a 
known  tuberculous  inflammation  has  become  complicated  by  a 
mixed  infection ;  whether  a  swelling  in  the  parotid  region  is  due  to 
some  other  infection  than  mumps;  whether  one  has  to  deal  with  a 
typhoid  or  an  appendicitis  or  peritonitis.  The  value  of  the  leu- 
cocyte count  depends  not  merely  upon  the  actual  number  of 
leucocytes,  but  greatly  upon  the  relative  proportion  of  the  poly- 
morphonuclears to  the  total  number  of  leucocytes.  In  the  increase 
of  leucocytosis  they  should  maintain  their  relative  proportion. 

Leucopenia  indicates  serious  malnutrition  or  severe  anemia,  or 
leukemia  complicated  by  an  infection,  or  infection  with  no  reaction 
against  it,  and  it  contra-indicates  operation  under  any  but  imper- 
ative circumstances. 

Eosinophilia  is  one  of  the  symptoms  of  malignant  tumors,  but 
it  may  also  be  present  in  leukemia,  in  trichinosis,  in  many  skin 
diseases,  in  scarlet  fever,  in  chronic  bronchial  affections. 

The  presence  of  glycogen  in  the  leucocytes,  as  determined  by 
the  iodin  test,  confirms  a  diagnosis  of  non-tuberculous  suppura- 
tion, and  while  not  always  present  in  suppuration,  it  may  sometimes 
be  found  when  the  leucocyte  count  is  low.  If  not  found  in  the 
known  presence  of  suppuration,  it  is  presumptive  that  the  inflam- 
mation  is  purely  tuberculous. 

The  uses  of  electricity  in  the  diagnosis  of  paralyses  and  their 
degenerations  are  the  same  in  children  as  in  adults.  But  its  appli- 
cation is  often  accomplished  with  difficulty,  owing  to  the  fear  and 
consequent  struggling  of  the  child,  or,  at  best,  the  usual  fidgetiness 
under  excitement.  The  formulse  of  the  qualitative  and  the  quan- 
titative reactions  in  health  and  in  disease,  with  descriptions  of  the 
apparatuses  are  fully  laid  down  in  the  works  on  electro  diagnosis 
and  therapeutics. 

The  X-ray  has  a  permanent  place  in  pediatric  as  in  general 
surgery,  more  especially  in  the  field  of  diagnosis,  but  also  in  the 
study  of  anatomic  development.  In  the  first  conflagration  of  enthu- 
siasm which  swept  round  the  world  after  the  announcement  of 
this  new  and  wonderful  form  of  force,  a  great  deal  of  damage  was 
done,  innocently  enough,  in  the  use  of  the  powerful  and  treacherous 
agent.  By  dear  experience  it  was  learned  that  the  use  of  the  ray  is 
not  without  danger.  That,  although  extremely  useful,  it  is  not  to  be 
employed  indiscriminately,  unnecessarily,  nor  carelessly.  It  is  capa- 
ble of  exerting  powerful  general,  as  well  as  local,  efifects,  appearing 
insidiously,  yet  lasting  persistently,  which  are  as  injurious  in  some 


EXAMINATION,    CASE-TAKING    AND    GENERAL    SUBJECTS    35 

cases  as  they  are  beneficial  in  others.  Not  only  do  the  well-known 
surface  burns  and  painful  keratoses  and  ulcerations  occur  months 
after  the  exposure,  which  at  the  time  caused  no  warning  sensation 
and  no  lesion,  but  profound  alterations  in  metabolism,  especially 
of  the  spleen,  the  lymphatic  tissues,  and  the  bone  marrow.^ 

Inhibition  of  growth  has  been  reported  by  several  observers, 
and  in  adults  sterility.  We  do  not  know  whether  permanent  changes 
in  the  glandular  structures  of  children  might  result.  But  one 
would  not  willingly  take  the  risk.  Special  caution  is  advised  in 
employment  of  the  X-ray  in  the  presence  of  nephritis,  of  toxemia, 
and  of  anemia  or  combinations  of  these  conditions.  The  condition 
of  the  patient  should  be  learned  and  the  necessity  or  utility  of  the 
use  of  the  ray  carefully  considered  before  it  is  resorted  to.-  This 
is  particularly  true  in  children,  who  should  have  all  portions  of  the 
person  not  necessarily  exposed  protected  from  the  ray  and  the 
time  of  exposure  as  short  as  possible.  If  the  exposure  must  be 
repeated  the  intervals  should  not  be  too  short  nor  the  repetitions  too 
many.  Exact  rules  cannot  yet  be  formulated,  but  these  are  the 
general  principles.  We  should  not,  however,  because  of  danger, 
abandon  the  use  of  so  valuable  an  agent.  The  surgeon's  knife 
and  anesthetic  also  are  deadly  if  used  without  caution,  knowledge 
and  skill.  We  are  yet  only  learning  how  to  use  the  X-ray  prop- 
erly. Knowledge  is  necessary  to  make  intelligible  radiographs.  It 
is  a  simple  enough  matter  to  get  a  view  with  the  fiuoroscope,  and 
even  to  make  and  develop  a  plate  and  print  from  it.  But  to  have 
the  radiograph  show  all  that  it  should  show,  t9  have  the  position  of 
patient,  the  distance  of  the  tube,  the  direction,  intensity  and  quality 
of  the  rays  regulated,  and  all  sources  of  error  excluded  and  to  do 
no  harm  to  patient  or  operator,  these  are  things,  with  many  more, 
yet  to  be  elucidated.  Specialists  are  at  work  endeavoring  to  discover 
the  laws  involved  and  to  standardize  the  whole  apparatus  and 
technique.  Knowledge  and  experience  are  necessary  to  properly 
interpret  a  radiograph.  We  have,  most  of  us,  learned  our  anatomy 
first  in  the  dissecting  room  and  afterward  in  the  practice  of  our 
art,  but  always  looking  at  the  surfaces  of  organs  and  tissues — not 
looking  through  them.  Only  in  imagination  had  we  seen  them  as 
they  are,  with  length,  breadth  and  thickness,  until  the  X-ray  re- 
vealed the  three  dimensions  at  one  view. 

Most  of  our  anatomy  was  learned  upon  the  adult  cadaver, 
and  afterward  as  pediatrists  we  were  obliged  to  learn  the  anatomy 
of  the  child.  Now  we  must  again  resume  our  studies  and  familiarize 
ourselves  with  radiographic  anatomy  before  we  can  read  with  un- 

1  Edsall,  Jour.  Am.  Med.  Ass'n,   Nov.  3rd,  '06. 

-  Forstcrling,     Centralblatt     fiir     Kinderheilkunde,     N.     Y.     Med.     Rec, 
Oct.   13th,   '06. 


36  SURGICAL   DISEASES    OF   CHILDREN 

derstanding  the  revelations  of  the  X-ray.  One  has  been  amused  to 
see  a  surgeon  who  would  not  think  of  breaking  that  good  rule  of 
comparing  the  diseased  limb  with  the  corresponding  sound  one,  take 
up  a  radiograph  of  a  child's  extremity  and  remark  upon  it  without 
pausing  to  think  that  he  had  not  a  normal  radiograph  for  com- 
parison and  was  quite  unfamiliar  with  the  radiographic  anatomy 
of  that  period  of  development.  Having  studied  the  normal  we 
may  appreciate  deviations  from  it.  True,  it  is  easy  enough  to 
see  the  shadowy  presentments  of  fractured  diaphyses  and  so 
to  correct  resulting  deformities,  especially  if  two  views  are 
taken  in  two  different  directions,  as  should  be  but  is  not  always 
done.  But  these  are  the  cases  in  which  the  diagnosis  and  the  cor- 
rection of  the  condition  are  perfectly  easy  without  the  X-ray.  It 
is  in  the  intraperiosteal  fractures,  which  are  more  common  in  infancy 
and  childhood  than  at  any  other  time  of  life,  and  in  the  puzzling 
injuries  near  joints  and  epiphyses,  and  in  the  changes  wrought  by 
arthritis,  osteomyelitis,  syphilis,  tuberculosis,  tumor  growth,  in 
questions  upon  the  normal  or  retarded  development  of  skeletal 
structures,  relative  to  renal  and  vesical  calculi  and  to  foreign  bodies 
lodged  in  the  respiratory  or  digestive  tract  or  buried  in  the  tissues, 
and  of  the  position  and  condition  of  viscera — these  are  the  cases 
in  which  knowledge  of  the  normal  radiographic  anatomy,  and  skill 
and  experience  in  the  interpretation  of  radiographs  are  indispen- 
sable to  the  intelligent  use  of  this  agent.  Unfortunately,  this  is  a 
form  of  knowledge  not  accurately  communicable  in  books,  because 
the  radiograph  is  only  rightly  read  in  the  negative.  Even  the  print 
fails  to  reproduce  what  is  seen  in  the  negative,  and  engraving  is 
still  more  unsatisfactory.  Only  the  rudiments  can  be  acquired  at 
second  hand.  Real  skill  must  be  acquired  at  first  hand  from  the 
study  of  patients  and  negatives.  When  both  radiographers  and 
surgeons  generally  have  reduced  the  making  and  interpreting  of 
radiographs  to  more  exact  rules  we  shall  have  something  intelligible 
and  reliable ;  and  a  great  number  of  the  pictures  now  on  our  shelves 
will  be  cast  aside  because  not  according  to  standard. 

Children  are  particularly  attractive  subjects  for  the  radiog- 
rapher, on  account  of  their  small  size  and  ready  permeability  by  the 
rays.  But  they  are  difficult  subjects,  for  the  reason  that  their  car- 
tilaginous bones  are  too  easily  permeated,  and  because  absolute 
immobilization  during  the  exposure  is  essential  to  fine  work,  and 
the  child  through  fear  of  the  crackling  and  flashing  apparatus  and 
the  strange  surroundings  is  the  most  difficult  of  patients  to  im- 
mobilize. Tact  and  patience,  together  with  the  avoidance  of  a 
strained  or  awkward  position,  aided  by  the  compression  tube,  or 
finally  an  anesthetic,  will  secure  success.  The  most  frequent  use 
of  the  X-ray  in  pediatric  surgery  is  in  the  study  and  diagnosis  of 


EXAMINATION,    CASE-TAKING    AND    GENERAL    SUBJECTS    37 

bone  and  joint  development,  injuries  and  diseases ;  and  next  in  use- 
fulness the  location  of  foreign  bodies.  The  epitheliomata  and 
the  superficial  forms  of  tuberculosis  in  which  the  ray  has  been 
found  useful  seldom  occur  in  children. 

Exploratory  punctures  and  incisions,  rectal,  vesical  and  vaginal 
explorations,  laryngoscopy,  bronchoscopy,  esophagoscopy,  gastro- 
scopy,  rhinoscopy,  otoscopy  and  other  methods  of  examination  have 
their  applications  in  appropriate  conditions  in  the  surgery  of  child- 
hood. 

To  complete  the  record  of  a  case  it  would  be  necessary  to  add 
the  diagnosis,  noting  any  diagnosis  that  had  been  previously  made, 
then  the  complications,  prognosis,  advice,  operation,  dressing  or 
other  treatment,  progress,  and  result.  In  some  forms  of  record  it 
is  useful,  too,  to  mention  whether  an  in-  or  out-  patient,  home  or 
office  patient,  or  where  seen,  and  whether  referred  by  another  phy- 
sician, or  seen  in  consultation. 

PREPARATION    FOR   AND    MANAGEMENT    AT    THE 
OPERATION 

Except  in  an  urgent  case  the  surgeon  should  see  that  the 
patient  to  be  operated  upon  is  in  good  condition,  with  all  the  organs 
not  involved  in  the  disease  or  injury  working  sufficiently  well. 
Many  an  operation  performed  in  the  most  workmanlike  manner 
has  failed  of  the  desired  result  because  the  patient  was  ill  nour- 
ished, anemic,  exhausted  or  otherwise  out  of  condition,  and  the 
operation  badly  timed.  But  extra  precaution  is  necessary  in  the 
examination  of  children  before  operation  on  account  of  their 
liability  to  the  sudden  onset  of  diphtheria,  the  exanthemata,  and 
especially  scarlatina  with  its  proclivity  for  attacking  wounds.  One 
may  be  obliged  to  do  tracheotomy  with  diphtheria  present  and  cer- 
tain to  infect  the  wound,  or  to  amputate  a  limb  or  resect  a  joint, 
knowing  that  amyloid  degeneration  has  occurred.  But  one  would 
not  undertake  to  correct  a  deformity  or  remove  an  innocent  growth 
or  perform  any  elective  operation  unless  the  general  condition  was 
first  made  as  good  as  it  could  be  hoped  to  attain.  Examine  the 
patient  and  take  the  temperature  before  any  operation  of  expe- 
diency. Inquire  whether  he  has  had  the  exanthemata,  especially  if 
there  is  any  scarlatina  or  other  infectious  disease  in  the  house  or 
among  the  playmates.  Ascertain  whether  the  child  be  a  hemo- 
philiac or  be  subject  to  convulsions  (Guersant).  The  former  should 
be  especially  prepared  for  an  operation  if  it  must  be  done,  and  in 
the  latter  case  extra  precautions  may  be  necessary  in  securing  the 
dressings.  The  results  of  some  operations,  for  instance,  a  hare-lip, 
may  be  entirely  frustrated  by  a  convulsion.  In  preparing  a  patient 
for  operation  not  only  the  heart  and  lungs  should  be  examined 


38  SURGICAL   DISEASES    OF   CHILDREN 

and  the  temperature  taken,  but  the  condition  of  the  kidneys, 
stomach,  spleen,  intestines  and  blood  should  be  ascertained.  In  all 
regulated  hospitals  there  is  a  standing-  rule  requiring  a  house  doctor 
to  make  the  necessary  urinary  tests  of  every  patient  before  opera- 
tion. But  this  is  most  apt  to  be  neglected  in  children,  especially 
if  a  specimen  of  urine  be  a  little  difficult  to  secure.  Prohibitive 
kidney  or  heart  disease  are  not  common  in  children,  yet  do  occur, 
and  the  surgeon  should  see  to  it  that  the  order  is  thoroughly  car- 
ried out  and  trouble  avoided.  The  blood  should  be  tested  for  hemo- 
globin in  any  case  possibly  anemic  before  any  operation  of  election. 
If  hemoglobin  is  low,  general  anesthesia  becomes  more  dangerous, 
collapse  more  probable,  recuperation  and  repair  after  operation 
less  likely  to  take  place.  General  anesthesia  lowers  hemoglobin. 
Sixty-five  per  cent,  is  a  low  normal  limit  in  a  child.  This  does 
not  deny  that  operation  may  be  successfully  done  if  necessary,  with 
a  hemoglobin  percentage  much  lower  than  sixty-five  per  cent.  But 
it  leads  one,  being  forewarned,  to  avoid  unnecessary  risk  when 
severe  operation  can  be  postponed,  or  to  take  extra  precautions 
against  shock,  hemorrhage,  and  other  untoward  events  in  a  case 
that  must  undergo  operation. 

In  a  jaundiced  case,  or  in  any  case  where  there  is  certain  to 
be  a  heavy  blood  loss,  its  coagubility  should  be  tested.  It  is  the  part 
of  prudence  to  inquire  concerning  hemophilia  in  the  family  of  any 
case  before  any  operation,  and  to  test  a  suspicious  case  with  a  small 
wound. 

A  single  laxative  the  day  or  evening  before  the  day  of  opera- 
tion does  not  always  thoroughly  empty  the  intestinal  tract  of  fecal 
contents.  A  thorough  clearing  of  the  canal  may  require  several 
days  or  a  week  or  more,  with  careful  regulation  of  the  diet,  and 
perhaps  use  of  medicines  to  prevent  fermentation.  A  stomach  or 
intestines  distended  even  with  gas,  while  especially  bad  in  an  opera- 
tion on  abdominal  or  pelvic  viscera,  is  an  evil  in  any  case  requiring 
general  anesthesia,  or  subjected  to  the  shock  of  operation.  In 
examining  the  urine  the  doctor  should  not,  as  is  too  often  the  case, 
content  himself  with  a  perfunctory  test  for  albumen,  but  should  use 
the  microscope,  and  should  not  fail  to  test  for  bile,  for  sugar,  and 
even  for  an  excess  of  uric  acid,  and  these  examinations  should  be 
made  upon  more  than  one  specimen.  It  is  noc  only  in  cases  of 
marked  jaundice,  as,  for  instance,  in  some  gallstone  cases  of  adults, 
that  hemorrhage  from  bile-poisoned  blood  takes  place,  but  in  slighter 
cases  of  hepatic  incompetence  with  bile  eliminated  in  part  by  way  of 
the  kidneys. 

In  infants  and  children,  prone  as  they  are  to  frequent  dis- 
turbances of  the  digestive  organs,  and  in  whom  the  integrity  and 
highest  efficiency  of  the  nutritive  functions  is  essential  to  successful 


EXAMINATION,    CASE-TAKING    AND    GENERAL    SUBJECTS    39 

surg-ery,  great  attention  should  be  directed  toward  the  state  of  the 
nutrition,  and  to  the  food,  before  any  serious  operation.  If  removal 
to  a  hospital,  or  the  nature  of  the  operation  will  require  a  change  in 
the  accustomed  food,  this  removal  and  this  change  should  be  made 
sufficiently  long  before  the  operation  to  demonstrate  its  safety  and 
practicability.  In  an  operation  of  any  magnitude  or  difficulty,  or 
where  strict  asepsis  is  necessary,  it  is  best  that  the  child  should 
be  removed  to  a  hospital ;  this  not  only  for  the  convenience  of  the 
surgeon  and  enabling  him  to  do  better  work,  but  for  the  care  of 
the  child  by  experienced  nurses.  In  some  cases  and  circumstances 
the  home  may  be  made  suitable  by  a  considerable  amount  of  prepa- 
ration. But  a  trained  surgical  nurse  should  be  called  in  to  make 
the  preparations  and  she  should  be  one  accustomed  to  the  nursing 
of  children.  With  children  old  enough  to  observe  their  surround- 
ings it  is  expedient  that  time  be  allowed  for  the  patient  to  become 
accustomed  to  the  hospital  or  acquainted  with  the  nurse ;  and  with 
children  accustomed  to  run  about,  a  few  days  an  bed  before  the  oper- 
ation will  render  them  much  more  reconciled  to  lying  still  afterward. 
Minor  operations,  pus  cases,  or  emergency  work  may  have  to  be 
done  at  the  home.  Do  not  depend  upon  a  parent  of  the  child  to 
hold  it  or  otherwise  assist  during  the  operation.  Parents  are  apt 
to  grow  nervous  and  unsteady,  or  by  their  emotion  tend  to  excite 
the  patient,  or  may  even  faint  and  draw  off  the  attention  of  one  of 
your  assistants,  or  may  suddenly  and  frantically  refuse  to  allow 
the  operation  to  proceed,  and  make  a  scene  which  will  sorely  try  the 
surgeon's  equanimity.  It  is  best  before  beginning  the  operation  or 
even  the  administration  of  the  anesthetic  to  insist  upon  the  parents, 
and  also  any  other  children  leaving  the  room,  assuring  them  that 
everything  possible  will  be  done  for  the  welfare  of  the  patient,  and 
they  must  quietly  abide  the  result.  The  other  children  are  ex- 
cluded not  only  to  prevent  disturbance  at  the  time,  but  because  it 
is  not  wise  to  let  children  witness  scenes  of  bloodshed.  Their 
faculty  of  imitation  is  developed  beyond  their  judgment,  and  their 
sensibilties,  even  if  they  are  not  shocked,  may  be  perverted.  It  is 
usually  asserted  that  children  do  not  suffer  from  apprehension  of 
an  expected  operation  and  are  often  indifferent  or  cheerful  or 
curious  about  it.  This,  fortunately,  is  true  of  most  young  children ; 
but  occasionally  with  older  children  they  suffer  extreme  dread,  the 
vivid  imagination  of  childhood  adding  tenfold  terrors  to  the  un- 
known ordeal.  Here  some  judgment  is  necessary  about  allowing 
a  child  to  know  beforehand  that  an  operation  is  to  be  done.  It  is 
well  to  avoid  any  display  of  instruments  or  apparatus ;  but  sleight- 
of-hand  smuggling  of  instruments  is  rarely  called  for,  often  a  fail- 
ure, and  outrages  the  child's  confidence.  The  best  time  of  day  for 
operation  is  usually  as  soon  as  possible  after  breakfast  time.  Though 


40  SURGICAL   DISEASES    OF    CHILDREN 

children  may  not  be  much  disturbed  through  apprehension,  they 
are  apt  to  be  not  only  impatient  but  perhaps  faint  or  depressed  for 
want  of  breakfast.  Power  is  quite  right  in  insisting  that  when  the 
operation  is  to  be  done  at  nine  or  ten  in  the  morning  the  patient 
should  take  a  good  sized  cup  of  warm  milk  at  seven  o'clock.  In 
this  country  we  are  apt  to  use  one  of  the  beef-peptone  or  malted 
milk  preparations,  according  to  the  child's  age,  or  similar  concen- 
trated food  with  little  bulk  and  almost  no  residue. 

ANESTHETICS 

The  use  of  anesthetics  is  often  indicated  and  seldom  contrain- 
dicated  in  children.  The  child's  fear  should  be  overcome  with  gen- 
tleness and  reassuring  words.  A  few  drops  of  perfume  on  the  in- 
haler may  aid.  Anesthetics  are  more  often  required  for  purposes 
of  examination  than  with  adults.  In  examining  all  cases  of  severe 
injury,  especially  about  bones  and  joints,  if  there  is  any  doubt  of 
the  diagnosis  it  is  well  to  anesthetize,  examine,  and  then  if  neces- 
sary reduce  and  dress  under  the  anesthetic.  At  the  first  dressing 
of  a  severe  burn  in  a  child  a  few  whiffs  of  an  anesthetic,  as  Owen 
suggests,  are  a  merciful  aid.  In  minor  operations  upon  young  in- 
fants, such  as  tenotomy  for  club-foot,  reduction  of  simple  fractures 
or  dislocations,  or  circumcision,  anesthesia  is  not  invariably  neces- 
sary. But  with  hare-lip,  incision  of  the  membrana  tympani,  or  the 
application  of  the  Paquelin  cautery,  anesthesia  should  be  used.  A 
painful  procedure,  even  though  not  serious  but  prolonged,  or  likely 
to  need  repetition,  like  electrolysis  for  nevus,  is  best  done  under 
anesthesia.  Anesthesia  during  intubation,  and  espeoially  during 
extubation,  is  recommended  by  some  authors,  but  is  quite  unneces- 
sary. Tracheotomy  requires  an  anesthetic  unless  the  child  is  un- 
conscious from  asphyxia.  The  same  preparation  for  anesthesia  by 
testing  the  vital  organs  and  unloading  the  primaevise  as  would  be 
done  with  an  adult  is  necessary.  While  cardiac  or  renal  disease 
which  would  make  anesthesia  extra  hazardous  or  fatal  are  not 
common  in  early  life,  they  can  occur,  and  the  status  lymphaticus  is 
not  uncommon  and  should  be  looked  for,  as  it  is  dangerous  with  any 
anesthetic,  especially  so  with  chloroform.  Respiratory  diseases 
which  would  affect  unfavorably  the  use  of  an  anesthetic  are  com- 
mon, but  readily  demonstrable.  With  any  obstructive  disease  of  the 
respiratory  tract  chloroform  is  usually  preferred  to  ether.  The 
author  cannot  agree  with  those  who  assert  that  anesthetics,  espe- 
cially chloroform,  are  almost  devoid  of  danger  in  children.  He  has 
several  times  seen  alarming  and  twice  very  alarming  conditions, 
though  fortunately  no  death  under  their  use.  One  of  the  worst 
cases  was  a  boy  of  two  years  and  another  a  girl  of  six.  In  both 
cases  chloroform  was  the  anesthetic.    The  symptoms  were  those  of 


EXAMINATION,    CASE-TAKING    AND    GENERAL    SUBJECTS    41 

suspended  respiration,  the  heart  continuing  to  act.  Perhaps  the 
feebler  development  of  the  respiratory  as  compared  with  the  cir- 
culatory systems  in  children  alters  the  effects  as  compared  with 
adults.  As  a  rule  children  bear  anesthesia  better  than  adults,  with 
less  nausea  and  quicker  recovery.  But  it  should  not  be  too  long 
continued.  Semi-anesthesia  is  admissible  in  infants,  and  there  seems 
to  be  less  danger  from  reflex  irritation  while  in  this  stage  than  in 
adults.  In  the  young  the  stage  of  rigidity  may  be  entirely  omitted 
and  complete  insensibility  quietly  take  place.  As  to  choice, 
of  anesthetic,  it  is  generally  taught  that  chloroform  is  better  as 
well  as  pleasanter  for  the  young  patient,  because,  their  hearts  being 
usually  unimpaired,  danger  of  a  failure  of  circulation  is  less  immi- 
nent, while  their  air  passages  being  small  the  mucus  secretion 
excited  by  ether  is  avoided.  But  of  late  years  surgeons  have  turned 
more  to  ether  as  undoubtedly  safer.  In  the  Boston  Children's  Hos- 
pital ether  is  used  entirely.  In  the  Hospital  for  Ruptured  and 
Crippled,  New  York,  ether  is  always  used  excepting  for  quite  young 
children  or  infants,  when  chloroform  is  used.  Thus  custom  varies. 
Notwithstanding  that  various  new  agents  are  exploited  from  time 
to  time  or  older  ones  revived,  practice  seems  to  adhere  to  ether, 
chloroform,  the  A.  C.  E.  mixture,  and  one  or  other  of  these  in  com- 
bination with  oxygen,  the  preference  being  for  chloroform  or  ether. 
Thus  nitrous  oxide  was  tried  again,  but  is  not  well  borne  by  in- 
fants and  young  children.  Ethyl  chloride  as  a  general  anesthetic 
acts  better,  but  while  very  powerful  is  so  very  transient  in  its  effect 
that  almost  any  operation  that  can  be  done  with  it  can  be  done 
without  it,  or  with  a  very  little  ether.  I  have  had  no  experience  with 
spinal  or  intra-neural,  nor  scopolamine-morphine  anesthesia  in  chil- 
dren. Nor  are  local  anesthetics  often  of  use  excepting  to  a  limited 
extent  upon  the  mucous  membranes  of  older  children,  or  the  ethyl 
chloride  spray  for  a  skin  incision,  (i) 

ASEPSIS   AND    ANTISEPSIS 

Asepsis  and  antisepsis  are  fully  as  important  in  the  surgery 
of  children  as  in  that  of  adults.  The  modern  tendency  to  asepsis 
rather  than  antisepsis  by  chemical  agents  is  particularly  beneficent 
in  its  application  to  the  surgery  of  childhood.  The  same  antiseptic 
agents  and  precautions  are  employed  and  in  much  the  same  manner, 
but  a  few  precautions  and  slight  modifications  of  methods  are  neces- 
sary. Children  are  especially  susceptible  to  poisoning  by  carbolic 
acid.  Some  surgeons  have  the  same  opinion  of  mercuric  prepara- 
tions, but  my  own  experience  would  lead  to  the  opinion  that  chil- 
dren are  comparatively  tolerant  systemically  of  mercury,  though 
the  skin  is  easily  irritated  by  strong  solutions.  Iodoform  ])oison- 
ing  is  complained  of  by  some  observers.    The  injection  of  iodoform 


42  SURGICAL   DISEASES    OF   CHILDREN 

emulsion  into  tuberculous  joints  and  cavities  is  nearly  abandoned, 
not  because  of  poisoning  but  because  of  failure  of  the  object  of  its 
use.  It  is  doubtless  well  to  avoid  too  free  use  of  it  either  in  powder 
upon  wounds  as  few  surgeons  employ  it  now,  or  in  packing  cavities 
with  iodoform  gauze,  as  is  frequently  done.  Sterile  gauze  or  cyan-, 
ide  or  borated  gauze  can  be  used  instead.  In  washing  out  suppurat- 
ing cavities  the  danger  of  using  carbolic  or  preferably  mercuric,  or 
still  better,  iodine  or  creolin  solutions  can  be  obviated  by  following 
the  antiseptic  wash  with  a  free  flushing  out  with  sterile  water  or 
normal  salt  solution.  Or  the  milder  germicides  can  be  employed. 
Such  is  Thiersch's  solution — salicylic  acid  2  parts,  boracic  acid  12 
parts  to  water  1000  parts.  Washing  of  cavities  with  anything 
is  less  indulged  in  than  formerly.  Of  those  mentioned  iodine  is 
perhaps  most  efficient.  In  many  cases  sterile  normal  salt  solution 
alone  answers  every  good  purpose  of  the  disinfectant  solution.  As 
dusting  powders  for  wounds,  finely  powdered  boracic  acid,  or 
boracic  acid  6  parts  to  iodoform  i  part;  or  campho-phenique,  or 
aristol,  or  zinc  oxide,  or  bismuth  subnitrate  used  freely.  All  dust- 
ing powders  should  be  impalpably  fine  and  sterile.  They  are  of 
questionable  utility  as  germicides  excepting  as  drying  agents,  but 
if  we  use  them  at  all  they  should  at  least  not  do  harm. 

In  preparing  the  skin  of  a  child  for  operation  its  delicacy  should 
be  borne  in  mind.  One  has  seen  it  abraded  by  friction  and  green 
soap  under  the  hand  of  an  over-zealous  assistant  accustomed  to 
preparing  for  operation  the  rugous,  seamy  skins  of  grimy  mechanics 
and  weather-beaten  teamsters.  Equal  care  should  be  used  but  less 
force.  A  piece  of  gauze  or  flannel  should  take  the  place  of  the 
scrubbing  brush,  and  the  soap  be  very  thoroughly  washed  off  with 
sterile  water  before  the  use  of  ether,  alcohol,  or  bichloride,  and 
these  latter  in  turn  should  be  followed  by  sterile  water.  It  is  easy 
to  produce  a  dermatitis  upon  a  child  in  preparing  for  operation. 

BANDAGING    AND    DRESSING    AND    THE    APPLICATION    OF 

SPLINTS 

Bandaging,  dressing  and  the  application  of  splints  upon 
children  constitute  a  fine  art.  Their  limbs  are  often  so  rounded  and 
soft,  lacking  the  angular  muscular  and  bony  markings  of  later  years, 
that  bandages  and  splints  easily  slip  about  and  become  loose.  If, 
in  order  to  avoid  this,  the  bandage  is  applied  too  tightly  or  too 
heavily,  as  is  very  apt  to  be  done,  the  soft  tissues  are  compressed, 
the  circulation  interfered  with,  the  skin  excoriated.  The  thoughtless 
or  willful  restlessness  of  the  child  adds  to  this  difficulty.  Careless- 
ness in  regard  to  wetting  with  urine  or  soiling  the  dressings  is  very 
annoying,  and  sometimes  really  hazardous  to  the  welfare  of  the 
wound.     Much  care  is  necessary  in  keeping  dressings  in  proper 


EXAMINATION,    CASE-TAKING    AND    GENERAL    SUBJECTS    43 

position  and  condition.  Rubber  sheeting  or  oil-silk  skillfully  dis- 
posed in  the  dressings  help  to  safeguard  the  wound.  Sometimes 
it  is  expedient  to  fasten  a  waterproof  conduit  to  the  urinary  organs 
by  means  of  adhesive  strapping.  When  splints  or  plaster  bandages 
are  liable  to  be  soiled  or  wetted  they  should  be  varnished  with  a 
solution  of  shellac  in  alcohol,  which  dries  quickly.  Perineal  bands 
can  be  treated  in  the  same  way,  but  can  often  be  substituted  by  a 
piece  of  pure  India  rubber  tubing,  which  withstands  water,  per- 
spiration and  urine.  Splints,  braces  and  trusses,  plaster  jackets  and 
bandages  should  be  frequently  inspected  to  see  that  there  is  no 
undue  pressure  or  chafing.  The  skin  beneath  their  edges  should  be 
kept  perfectly  clean  and  dry,  and  powdered  with  equal  parts  of 
lycopodium  and  oxide  of  zinc,  or  powdered  talc  and  boric  acid,  or 
similar  dressing.  Stuffing  bits  of  absorbent  cotton  under  only 
makes  matters  worse.  When  making  a  dressing  everything  that 
will  be  needed  should  be  at  hand  before  the  work  is  begun.  If  the 
dressing  is  painful  it  should  be  completed  with  dispatch.  Children 
will  bear  sharp,  momentary  pain  bravely,  but  will  break  down  if 
the  pajin  or  apprehension  of  pain  is  prolonged  or  repeated.  In 
dressing  an  extensive  burn  it  should  not  all  be  uncovered  at  once, 
nor  be  long  uncovered.  The  fresh  dressings  should  be  ready,  in 
sections,  and  after  the  cleansing  quickly  applied. 

The  Plaster  of  Paris  Bandage  or  Splint  is  almost  invaluable 
in  pediatric  surgery.  Its  adaptability  to  shape  and  its  firmness,  not 
to  mention  its  cheapness,  recommend  it.  Silicate  of  soda,  molded 
millboard,  poroplastic  felt,  leather,  wood,  woven  wire,  shaped  sheet- 
metal,  steel  frames,  and  other  materials  have  their  uses  and  their 
advocates ;  but  plaster  of  Paris  still  holds  first  place  for  general 
usefulness,  for  firm  fixation  without  undue  pressure  at  any  point. 
Any  surgeon  knows  how  to  put  on  a  good  plaster  bandage,  but  not 
every  surgeon  puts  on  a  good  plaster  bandage.  There  is  an  art  in  it 
that  has  to  be  acquired  by  practice.  Fresh  and  fine  dental  plaster 
only  should  be  used.  It  is  generally  used  in  the  form  of  a  roller 
of  open  meshed  crinoline.  The  two  and  a  half  and  three  inch  sizes 
are  most  frequently  useful.  Occasionally  a  two-inch  roller  will  be 
handy  for  a  small  extremity.  The  dry  plaster-roller  being  immersed 
in  water  till  the  bubbles  cease  to  rise  is  then  deftly  applied  spirally 
without  reverses,  each  layer  being  rubbed  over  with  the  wetted 
hand ;  and  this  process  repeated  until  the  desired  thickness  is  pro- 
duced. Cold  water  delays  the  setting  of  the  plaster  and  hot  water 
hastens  it.  In  England  plaster  is  often  used  with  "  house-flannel," 
which  is  nearly  as  thick  as  a  blanket.  The  flannel  is  cut  to  the  size 
and  shape  suitable  to  the  part  to  be  splinted,  and  then  having  been 
saturated  with  a  creamy  mixture  of  plaster  and  water  can  be  very 
quickly  applied  and  secured  in  place  with  an  ordinary  or  a  plaster 
roller.    Such  a  plaster  splint  can  be  more  quickly  removed  tlian  the 


44  SURGICAL   DISEASES    OF   CHILDREN 

bandage  put  on  spirally.  In  applying  a  plaster  roller  care  should 
be  taken  not  to  draw  the  turns  too  tightly.  The  bandage  need 
not  be  so  thick  as  to  be  burdensome.  It  is  important  to  have  the 
parts  to  be  bandaged  held  in  the  desired  position  before  the  appli- 
cation of  the  bandage  is  begun,  during  the  entire  time  of  its  applica- 
tion and  afterward  until  the  plaster  sets.  To  change  the  position 
after  the  bandage  is  on  or  partly  on  may  cause  ulceration  or  worse 
from  pressure  where  it  wrinkles.  The  parts  should  be  carefully  held 
without  pressure  upon  the  plaster  until  it  sets  firmly,  which  should 
take  but  a  few  minutes.  While  the  plaster  is  still  soft  its  edges 
should  be  smoothed  and  slightly  everted  with  the  finger.  A  spoon- 
ful or  two  of  sugar  in  washing  the  hands  helps  in  the  removal  of  the 
plaster.  Rubber  gloves  save  time  and  preserve  the  surgeon's  hands 
from  roughness.  The  removal  of  a  plaster  bandage  is  difiQcult  to 
those  unaccustomed  to  the  work.  It  can  be  done  with  a  pocket 
knife,  or  better  with  a  pruning  knife.  There  are  in  the  market 
numerous  plaster  bandage  shears,  saws,  and  other  cutters  which 
will  not  cut,  and  guards  to  protect  the  skin.  My  own  preference 
is  for  Engel's  saw  or  Esmarch's  knife.  The  former  has  a 
crescentic  blade  like  a  Hey's  saw,  but  much  stronger.  It  is 
useful  to  cut  a  very  heavy  bandage  or  a  jacket  or  cast  which 
is  to  be  "  sprung "  off  and  used  again.  The  Esmarch  knife  is 
for  ordinary  use.  It  has  a  short,  strong  blade  and  a  good- 
handle,  the  butt  of  which  tapers  to  a  wedge  that  is  useful  for 
raising  or  separating  the  cut  edges.  The  trick  of  using  the  knife 
is  in  beginning  at  the  edge  and  in  cutting  diagonally  through  the 
plaster  instead  of  at  right  angles  to  the  surface.  The  plaster  hav- 
ing been  wetted  with  water,  which  is  just  as  good  as  acetic  acid  or 
anything  else,  the  upper  edge  should  be  raised  with  the  left  hand 
and  cut,  and  as  the  cutting  proceeds  one  side  is  steadily  drawn  away 
from  the  skin  surface.  The  old-fashioned  Heister's  mouth-gag  is 
handy  for  separating  the  cut  edges  of  a  heavy  cast.  The  plaster 
bandage  is  useful  for  immobilization  of  almost  any  part  that  is  not 
subject  to  rapid  swelling  or  does  not  require  daily  inspection  or 
dressing.  Even  in  these  latter  cases  it  can  be  used  by  making  a 
suitable  window  over  the  wound  or  sinus.  It  is  very  useful  in 
fractures  after  the  first  swelling  has  subsided.  It  is  often  used  after 
hernia  operations  in  children.  Spinal  caries  is  frequently  and  suc- 
cessfully treated  by  immobilizing  with  the  familiar  plaster  jacket 
or  collar,  hip- joint  disease  with  the  plaster  spica,  and  other  tuber- 
culous joints  are  kept  at  rest  by  the  same  convenient  means.  One 
of  its  most  useful  applications  is  in  the  treatment  of  clubfoot,  in 
maintaining  the  corrected  or  overcorrected  position  after  this  has 
been  obtained  by  force  or  by  cutting  operation ;  and  no  shoe,  splint 
or  other  device  is  so  successful  and  so  safe  in  this  class  of  cases. 


EXAMINATION,    CASE-TAKING    AND    GENERAL    SUBJECTS    4S 
HEMORRHAGE    AND    ITS    CONTROL 

The  proportion  of  blood  to  body-weight  is  stated  by  physi- 
ologists to  be,  in  the  adult,  as  i  to  12  or  14,  or  an  average  or  i  to  13, 
or  about  8  per  cent.  In  the  new-born  child  the  blood  is  about  5 
per  cent,  of  the  body-weight.  In  a  case  of  hemorrhage  in  an  adult, 
very  dangerous  symptoms  supervene  upon  the  loss  of  one-half  the 
total  quantity  of  blood,  and  death  ensues  when  a  little  over  5  of  the 
8  per  cent,  has  been  lost.  A  dangerous  quantity  from  an  original 
supply  of  only  5  per  cent,  would  very  soon  ebb  away.  Does  the 
smaller  proportion  of  blood  account  for  the  fact  that  hemorrhage 
is  badly  borne  by  the  infant? 

But  as  "the  individual  does  not  perish  from  want  of  blood, 
but  from  want  of  motion  of  the  blood,"  ^  and  as  the  motion  cannot 
be  maintained  without  a  proper  degree  of  tension,  it  may  be  that 
the  tension  is  originally  low,  so  that  a  small  loss  serves  to  depress 
it  fatally.  One  factor  in  producing  arterial  tension  is  the  propor- 
tion between  the  volume  of  the  heart  as  compared  with  the  width 
of  the  arteries.  According  to  Beneke,  in  the  adult  the  volume  of 
the  heart  bears  the  proportion  to  the  width  of  the  aorta,  of  290  to 
61.  Before  puberty  it  is  as  140  to  50,  while  in  the  infant  it  is  as 
25  to  20.  Is  this  the  reason  for  low  tension?  However,  arterial 
tension  is  influenced  also  by  the  vaso-motor  system  as  well  as  by 
the  caliber  of  the  vessels  and  quantity  of  the  blood.  Can  it  be  that 
the  undeveloped  nervous  system  of  the  young  is  at  fault  in  main- 
taining vascular  tension?  The  rapidity  of  blood  loss  is  a  large 
factor  in  producing  the  depression  which  follows,  as  was  often 
observed  in  the  days  when  phlebotomy  was  in  common  practice. 
The  tissues  are  said  to  be  more  liberally  supplied  with  arteries  and 
arterioles  in  proportion  to  the  veins,  and  consequently  a  less  pro- 
portion of  the  blood  would  be  contained  in  a  slow-moving  venous 
current.  Does  a  child  bleed  more  rapidly  than  an  adult?  Or  have 
his  blood  elaborating  organs  a  smaller  working  capacity?  (2) 

These  queries  are  given  for  want  of  anything  better  to  ac- 
count for  the  generally  accepted  observation  that  children,  and 
especially  infants,  bear  hemorrhage  very  badly.  Whatever  the 
physiological  reason,  it  is  plain  that  he  who  essays  to  operate  in 
vascular  tissues  upon  a  child  should  be  versed  in  the  methods  and 
supplied  with  the  means  for  the  control  of  hemorrhage,  and  know 
the  necessity  for  economy  of  blood.  The  Esmarch  bandage  should 
be  used  in  all  operations  upon  the  extremities  in  which  the  subse- 
quent oozing  will  not  be  especially  detrimental,  and  in  all  dissections 
enough  hem.ostatic  forceps  should  be  at  hand,  and  used  freely. 
When  possible,  vessels  should  be  caught  between   forceps  before 

1  Vergl.     Auch     L.     von     Lesser.       Transfusion     und     Autotransfusion, 
Samml.  Klin.  Vottrage  ver.  86. 


46  SURGICAL   DISEASES    OF   CHILDREN 

severing.  When  necessary,  vessels  should  be  tied,  but  fewer  liga- 
tures will  be  used  in  proportion  to  the  number  of  hemostats,  for  the 
child's  vessels  contract  well  after  the  use  of  the  torsi-pressure. 
Where  there  are  oozing  surfaces  hot  gauze  sponges  or  irrigation 
with  hot  normal  salt  solution  should  be  used ;  cavities  may  be  packed 
with  gauze :  in  suitable  situations  the  thermocautery,  the  hot  or  cold 
wire  snare  or  the  galvanic  knife  employed,  and  every  care  exerted 
to  save  blood. 

SHOCK 

It  has  been  my  experience,  and  I  believe  this  accords  with  the 
experience  of  all  pediatric  surgeons,  that  children  bear  starvation, 
hemorrhage,  cold,  and  pain  very  badly,  and  that  they  suffer  severely 
from  shock  under  injury  and  operation.  That  peculiar  condition  of 
general  depression  which  we  call  shock  seems  to  be  a  composite  of 
lowered  states  of  various  functions,  which  may  vary  somewhat  in 
their  several  degrees,  yet  all  contributing  to  make  the  picture  of 
partially  suspended  animation.  The  patient  is  dazed  yet  conscious, 
the  mental  faculties  clear  but  acting  feebly.  The  nerve  centers  are 
slow  to  receive  and  to  send  out  impulses.  The  cutaneous  and  other 
reflexes  are  slow  if  not  absent.  The  pupils  react  feebly  and  are 
probably  dilated.  The  skin  and  mucous  membranes  are  pale,  and 
the  former  covered  with  cold  perspiration.  The  pulse  is  rapid  and 
weak,  the  respiration  shallow,  and  the  temperature  below  normal. 
Last  to  be  mentioned,  but  not  least  in  im.portance,  the  blood  pressure 
is  lowered.     Yet  no  one  of  these  alone  constitutes  shock. 

There  is  available  much  accumulated  knowledge  of  shock,  not 
only  through  the  observations  of  very  numerous  clinicians,  but 
through  valuable  experimental  studies  by  Lennander,  Crile,  Erlanger, 
Hooker,  and  Howell,  and  many  physiologists  and  surgeons.  It  is 
understood  that  shock  may  be  produced  by  different  causes,  and 
that  the  various  phenomena  combining  to  make  up  the  symptom 
group  called  shock  may  vary  in  their  relative  prominence  in  differ- 
ent cases.  For  instance,  Howell  distinguishes  between  vascular 
shock  and  cardiac  shock.  And  yet  we  have  not  a  complete  under- 
standing of  the  physiology  of  its  production.  Nor  has  any  accepted 
classification  been  arrived  at.  (3) 

In  this  unsettled  state  of  knowledge  it  will  obviously  be  im- 
possible for  me  to  offer  anything  conclusive  on  the  subject  of  shock 
in  children.  Yet  the  observations  of  clinicians  upon  this  subject 
have  so  far  generally  been  borne  out  by  the  physiologists  and  ex- 
perimenters, and  it  may  be  worth  while  to  combine  the  accepted 
knowledge  available  with  experience  of  the  conditions  as  found  in 
children's  surgery  and  evolve  a  practical  lesson  for  the  pediatric 
surgeon.     Reviewing  the  factors  productive  of  shock  as  occurring 


EXAMINATION,    CASE-TAKING    AND    GENERAL    SUBJECTS    47 

in  the  adult,  it  would  seem  that  some  of  them  are  more  powerfully 
operative,  while  others  would  scarcely  ever  enter  into,  the  problem 
of  shock  in  the  infant  or  child.  Starvation  or  malnutrition,  athrep- 
sia,  is  a  condition  clinical  observation  would  lead  one  to  consider 
particularly  prone  to  the  depressing  influences  producing  shock. 
And  while  this  is  no  doubt  true  of  the  adult,  it  is  more  emphatically 
true  of  the  very  young.  The  infant  or  the  child  whose  nutrition  is 
poor,  who  is  losing  weight,  no  matter  whether  this  is  due  to  dis- 
ordered digestion  or  to  an  obstruction  somewhere  in  the  digestive 
tract,  will,  if  subjected  to  operation,  suffer  a  more  than  ordinary 
degree  of  shock  and  be  slow  and  difficult  to  rally.  This  forbids 
operations  of  election  such  as  that  for  hare-lip  or  hypospadias  or 
other  external  deformity  in  marasmic  or  ill-nourished  patients.  It 
darkens  the  prognosis  in  operations  for  stenosis  of  the  pylorus, 
stricture  of  the  esophagus,  or  any  obstruction  in  the  digestive  tract 
which  has  produced  partial  starvation. 

Hemorrhage  has  long  been  known  to  be  one  of  the  powerful 
factors  in  the  production  of  shock.  According  to  Crile's  researches 
it  has  this  effect  even  if  it  does  not,  as  usual,  cause  much  lowering 
of  blood  pressure.  All  pediatric  surgeons  are  agreed  that  hemor- 
rhage is  one  of  the  principal  causes  of  shock  and  bad  operative 
results  in  the  young,  and  practical  as  well  as  theoretical  remarks 
on  the  subject  will  be  found  in  a  preceding  section  of  this  book. 

Cold. — Exposure  to  cold  is  placed  by  Wright  as  next  to  hem- 
orrhage in  its  depressing  effect  upon  children.  Whether  this  is 
due  to  their  small  size,  the  small  volume  of  blood  in  circulation,  or 
to  the  thinness  and  vascularity  of  the  skin  or  to  an  easily  affected 
heat  center,  might  be  difficult  to  determine.  But  the  practical  les- 
son is  that  the  child  upon  the  table  should  be  well  protected  by 
warm  clothing,  exposing  only  the  field  of  operation.  The  limbs 
should  be  protected  by  cotton  batting  bandaged  on.  If  the  operation 
is  to  be  severe,  it  is  best  to  use  a  water  mattress  at  a  temperature  of 
100  F.  upon  the  operating  table,  or  hot-water  bags  disposed  about 
the  patient.  After  washing  the  field  of  operation  the  wet  towels  or 
sheets  should  be  removed,  and  dry  sterile  ones  substituted,  for  a 
wet  surface  is  soon  chilled.  Exposed  tissues  should  be  covered  as 
much  as  possible  with  warm  gauze.  And  the  patient's  bed  should 
be  so  prepared  for  his  reception  as  to  maintain  his  animal  heat. 

Heat. — In  this  connection  heat  should  be  referred  to  as  a  cause 
of  shock,  both  as  in  a  case  of  burn  and  as  summer  heat.  As  is 
well  known,  burns  of  the  skin-surface  produce  severe  shock,  and 
this  in  proportion  to  the  area  of  the  skin  burned  and  not  to  the  depth 
of  the  burn,  the  shock  evidently  resulting  from  the  injury  to  the 
numerous  nerve  endings.  Summer  heat  has  not  been  classed  as  a 
factor  particularly  predisposing  to  shock,  yet  its  known  depressing 


48  SURGICAL    DISEASES    OF    CHILDREN 

influence  upon  infants,  and  the  prevalence  of  diseases  of  nutrition 
in  the  heated  term,  would  incline  us  when  we  may,  to  choose  a  cooler 
season  for  operations  of  any  magnitude. 

Duration  of  Anesthesia  and  of  Operation. — Anesthesia 
must  be  considered  a  cause  of  shock  to  which  children  are 
sensitive,  although,  as  stated  in  a  preceding  section,  it  is  well  borne 
if  not  prolonged.  Shock  from  trauma  of  operation  bears  a  rela- 
tion to  the  duration  as  well  as  to  the  violence  of  the  traumatism. 
Every  effort  should  be  made  to  expedite  the  work.  Everything 
should  be  in  readiness  before  the  work  is  begun,  instruments  in 
place  and  needles  threaded.  The  patient  should  not  be  anesthetized 
beforehand  and  be  kept  waiting  in  anesthesia  till  preparations  are 
completed.  Nothing  can  be  more  exasperating  to  a  conscientious 
surgeon  with  a  child  upon  the  table  than  a  dilatory  nurse  or  a  fum- 
bling assistant.  Everyone  assisting  should  be  given  to  understand 
that  from  the  word  "  Ready  "  every  step  is  to  progress  without 
hurry  but  without  delay  to  the  completion  of  the  operation. 

The  degree  of  the  effect  of  manipulation  of  the  various  organs 
or  tissues  on  blood  pressure  and  as  a  factor  of  shock  should  be 
familiar  to  the  surgeon.  The  important  contributions  of  Crile  to 
this  subject  are  well  known.  Likewise  the  contributions  of  Len- 
nander  on  the  relative  sensitiveness  of  different  tissues.  A  discus- 
sion of  these  points  need  not  be  entered  into  here,  as  I  have  no 
evidence  that  the  general  principles  involved  are  any  different  in 
children  than  those  in  adults.  In  connection  with  these  two  sub- 
jects of  duration  of  the  operation  and  the  effects  of  manipulation, 
I  cannot  do  better  than  to  quote  the  following  from  Bloodgood's 
admirable  article  in  Bryant  and  Buck's  American  Surgery: 
"  Within  certain  limits  of  time,  I  do  not  believe  that  the  general 
anesthetic  or  the  exposure  of  tissues  to  the  air  is  as  important  a 
factor  in  producing  shock  as  the  rough  handling  of  tissue.  It 
frequently,  then,  becomes  a  choice  of  evils,  and  personally  I  would 
prefer  a  little  longer  operation  for  a  gentle  dissection,  bloodlessly, 
to  a  shorter  operation  with  more  hemorrhage  and  rough  handling." 

But  the  principle  that  the  greater  the  injury  or  irritation  of 
sensory  nerves  the  greater  the  effect  on  the  vaso-motor  centers  and 
the  consequent  shock,  I  think  has  a  particular  force  when 
applied  to  children,  because  the  delicacy  of  their  tissues  and  the 
smallness  of  their  anatomical  spaces  renders  unnecessary  and  dam- 
aging trauma  exceedingly  liable  to  occur.  Therefore  with  them 
the  very  gentlest  manipulation,  the  most  accurate  dissection  with 
the  sharpest  of  instruments  is  imperative.  Dragging  upon  organs 
or  tissues  and  tearing  or  blunt  dissection  should  be  avoided  even 
more  assiduously  than  in  the  adult. 

QxHEii  Factors  of  Shock. — We  now  come  to  mention  briefly 


EXAMINATION,    CASE-TAKING    AND    GENERAL    SUBJECTS     49 

certain  other  factors  which  are  usually  considered  in  a  causative 
relation  to  shock.  Fear  or  dread  of  operation  or  of  a  resultant 
impairment  are  absent  entirely  in  the  case  of  the  very  young.  If 
surrounding  friends  are  judicious  enough  to  maintain  silence  as 
to  the  commg  ordeal  and  its  results,  they  are  a  very  small  factor 
with  older  children.  If  a  child  is  comfortable  and  amused  for  the 
present  hour  he  is  happy.  He  has  no  regrets  for  the  past  nor 
fears  for  the  future.  He  is  not  depressed  by  brooding  over  his 
condition,  and  after  the  operation  soon  becomes  accustomed  to 
confinement  to  bed  and  makes  the  best  of  it. 

Autointoxication  probably  exerts  the  same  baleful  influence 
upon  the  child  that  it  does  upon  the  adult.  There  is  no  evidence 
to  show  that  it  is  more  or  less.  But  excepting  in  cases  of  mal- 
formation of  rectum,  imperforate  anus,  or  acute  obstruction  of 
the  intestinal  tract,  such  a  "  stercoremia  "  is  very  unlikely  to  occur. 
The  chronic  intestinal  obstructions  and  obstipations  comparatively 
frequent  in  adults  are  rare  in  childhood. 

Alcoholism  is  an  element  of  danger  in  anesthesia  and  in  in- 
jury and  operation  which  can  be  counted  out  of  the  list  in  chil- 
dren's surgery.  Diabetes,  whether  as  dangerous  under  operation 
as  it  is  sometimes  represented,  need  not  be  considered ;  and  ne- 
phritis, while  not  common,  could  be  found  if  present,  and  precau- 
tions taken.  As  to  cases  of  infection,  whether  general  or  local,  it 
is  my  impression  that  while  the  young  are  very  prone  to  be  at- 
tacked by  them,  the  resistant  forces  also  rally  quickly,  and  there  is 
more  to  be  hoped  from  the  young  than  from  their  elders  under 
similar  conditions.  Anemia,  whether  in  young  or  older  patients, 
is  not  a  promising  condition  for  operation.  Yet  if  Bloodgood's 
excellent  advice  were  followed  and  the  surgeon  would  insist  upon 
a  complete  blood  count  in  all  cases  where  there  is  clinical  evidence 
of  anemia,  or,  indeed,  in  every  instance,  believing  it  more  important 
than  an  examination  of  the  urine,  he  would  seldom  get  into  diffi- 
culty because  of  anemia.  Jaundice  is  a  condition  not  very  likely 
to  be  met  in  a  child  requiring  operation,  unless  it  were  in  the 
new-born.     Then,  if  possible,  the  operation  should  be  postponed. 

Diagnosis. — The  diagnosis  of  shock  is  easy  in  a  typical  case, 
but  may  be  difficult  in  a  slighter  case;  but  instructions  upon  the 
diagnosis  are  not  easy  to  write.  The  art  must  be  learned,  to  a 
great  extent,  by  experience.  If  one  will  remember  the  principal 
phenomena  of  a  marked  case  and  be  prepared  to  observe  them 
even  though  manifested  in  slighter  or  varying  degrees,  he  will 
probably  appreciate  the  condition  of  his  patient  in  time  to  be  of 
the  greatest  service  to  him.  The  dazed  or  listless  condition  of  the 
mind,  with  the  abatement  of  the  reflexes  and  the  pallor,  are  differ- 
ent from  the  alertness,  the  nervousness  and  anxiety  and  the  flush 


50  SURGICAL  DISEASES   OF  CHILDREN 

of  the  patient  who  is  frightened  or  excited  rather  than  shocked. 
The  clammy  skin,  the  rapid,  feeble  pulse,  the  shallow  respiration, 
call  for  immediate  attention  to  the  condition  of  shock.  The  prob- 
abilities are  that  if  the  child  survives  the  immediate  effect  of 
the  injury,  and  shows  any  power  of  reaction,  and  there  has  been 
no  blood  lost,  that  he  will  recover  from  the  shock.  Or  that  if  upon 
the  operating  table  with  a  patient  previously  in  good  condition  the 
anesthetic  be  immediately  withheld,  the  operation  suspended  and 
treatment  instituted,  that  he  will  recover.  If  the  child  was  feeble, 
and  especially  if  there  has  been  hemorrhage,  the  prognosis  is  much 
darkened.  If  reaction  takes  place  it  will  come  but  slowly  and  com- 
plications are  likely  to  supervene. 

Treatment. — Anything  which  could  increase  shock,  such  as 
an  anesthetic,  operation,  manipulation  of  tissues,  should  be  inter- 
dicted, even  if  the  unfinished  operation  must  be  resumed  at  some 
future  time.  The  patient  should  lie  upon  the  back,  with  the  head 
low  and  the  feet  elevated.  The  angle  may  be  forty-five  or  more 
degrees,  temporarily.  Oxygen  should  be  administered,  especially 
if  anesthesia  had  been  used.  Artificial  heat  should  be  applied  to 
maintain  the  normal  body  temperature.  Small  doses  of  morphia 
should  be  used  subcutaneously  as  soon  as  the  patient  regains  con- 
sciousness, and  if  there  is  pain  enough  should  be  used  to  control 
it — remembering  the  susceptibility  of  the  young  to  this  drug.  The 
extremities  and  abdomen  should  be  bandaged  firmly  toward  the 
heart,  preferably  with  cotton  beneath  the  roller.  This  is  quickly 
and  easily  accomplished  in  children.  Salt  solution  should  be  given 
at  a  temperature  of  105  F.,  or  at  least  above  the  normal,  and  also 
subcutaneously.  If  there  has  been  hemorrhage  a  larger  amount 
should  be  used  than  if  there  has  not.  If  the  condition  is  very 
critical  the  salt  solution  should  be  given  intravenously.  It  is  prob- 
able that  if  there  has  been  no  hemorrhage  the  salt  solution  will  not 
be  so  efficacious  in  relieving  the  shock,  but  it  is  not  harmful  and 
should  be  used  in  all  cases.  The  necessary  apparatus  is  very 
simple,  consisting  of  a  needle  or  canula  tied  into  the  end  of  a  yard 
or  two  of  flexible  rubber  tubing,  to  the  other  end  of  which  is 
attached  a  glass  funnel,  an  irrigation  bottle  or  a  rubber  bag.  The 
ordinary  fountain  syringe  answers  the  purpose.  The  apparatus  as 
well  as  the  solution  should,  of  course,  be  carefully  sterilized,  and  in 
every  hospital  should  be  kept  ready  for  immediate  use.  The 
solution  is  made  by  dissolving  dried  granulated  salt  in  sterile 
water  in  the  proportions  of  a  drachm  to  the  pint,  filtering  into 
sterilized  flasks,  stoppering  with  non-absorbent  cotton  and  sterilizing 
for  one  hour  at  a  temperature  of  220  degrees  F.  for  three  successive 
days.  For  intravenous  injection  one  of  the  superficial  veins  in  front 
of  the  elbow  should  be  exposed,  and  this  procedure,  as  D'Arcy 


EXAMINATION,    CASE-TAKING   AND    GENERAL    SUBJECTS    51 

Power  remarks,  "  is  no  easy  operation  in  a  bloodless  child."  It  may 
be  necessary  to  expose  one  of  the  venae  comites  of  the  brachial  in- 
stead. The  vein  being*  exposed  and  a  ligature  thrown  around  it,  the 
needle  or  canula  (the  solution  having  been  first  allowed  to  run 
through  enough  to  expel  the  air)  is  thrust  into  the  vessel  with  its 
point  toward  the  heart,  and  the  ligature  half  tied.  The  solution  is 
then  allowed  to  flow,  slowly,  or  more  rapidly  if  the  case  is  urgent. 
There  is  no  danger  of  introducing  too  much  of  the  solution,  from 
a  few  ounces  to  a  half  pint,  or  a  pint,  usually.  It  is  usual  to  allow 
it  to  flow  till  the  pulse  shows  an  improvement  by  becoming  slower, 
fuller  and  with  better  tension,  and  then  soon  after,  the  canula  or 
needle  is  removed,  the  ligature  drawn  tight  and  the  tying  com- 
pleted, and  the  wound  dressed.  The  needle  or  canula  can  be  left 
in  the  vein  for  some  hours  and  the  injection  repeated  if  necessary. 
Usually  if  a  child  is  going  to  recover  he  does  so  promptly.  Strych- 
nine has  lost  its  reputation  with  many  as  a  remedy  for  shock,  yet 
is  still  used  by  some,  in  at  least  one  dose,  Montgomery  uses,  also, 
aseptic  ergot.  Som.e  use  hot  coffee  or  whisky  with  the  salt  enema. 
Adrenalin  chloride  in  salt  solution  (i  to  20,000)  is  greatly  recom- 
mended, but  until  it  or  some  other  agent  can  be  proven  more  reli- 
able and  lasting  in  its  effects,  it  will  be  better  to  depend  on  the  salt 
solution,  with  position,  oxygen  and  heat,  and  perhaps  massage  over 
the  heart. 

Hypodermoclysis  is  done  with  the  same  kind  of  apparatus  as 
is  used  for  intravenous  injection.  The  skin  of  the  pectoral  region 
is  prepared  by  antiseptic  washing,  and  the  needle  (after  allowing 
the  air  to  escape)  is  thrust  in  at  the  outer  edge  of  the  pectoral 
muscles,  pointing  toward  the  axilla.  Or  it  can  be  introduced  at 
the  lower  angle  of  the  scapula  or  over  the  flank  or  abdomen.  The 
solution  runs  slowly  till  the  tissues  will  not  retain  more  without  too 
much  tension  for  rapid  absorption.  (4) 

AFTER  OPERATION 

After  operation  (5)  a  good  rule  is  to  give  a  rectal  enema  of  a 
few  (two  to  eight)  ounces  of  normal  salt  solution  at  a  temperature 
of  100  degrees  F.,  and  if  the  operation  was  moderately  severe  this 
should  be  repeated  at  intervals  of  four  hours  for  the  first  twenty- 
four  or  thirty-six,  as  it  helps  to  prevent  shock  and  allays  the  anes- 
thesia thirst.  The  bed  should  have  been  carefully  prepared  with 
hot  water  bottles  a  half  hour  before  the  conclusion  of  the  opera- 
tion, and  the  child  should  be  placed  therein  in  the  easiest  possible 
position  in  regard  to  the  wound,  and  yet  so  that  vomited  matters 
may  readily  escape  from  the  mouth.  He  should  be  constantly 
watched  till  consciousness  is  fully  established  and  he  is  taught  not 
to  toss  about  nor  interfere  with  the  dressings.     Generally  young 


52  SURGICAL   DISEASES    OF   CHILDREN 

patients  recover  from  an  anesthetic  sooner  than  adults.  Oxygen, 
either  in  the  form  of  the  pure  gas  or  obtained  by  free  ventilation, 
is  the  best  of  treatment,  but  if  nausea  proves  distressing  and  per- 
sistent, lavage  may  stop  it.  If  pain  is  present  it  should  be  con- 
trolled by  an  opiate.  Children  bear  severe  or  prolonged  pain  very 
badly.  That  is,  it  depresses  them,  and,  following  an  operation,  it 
adds  to  and  prolongs  shock.  The  opiate  should  be  repeated  as 
necessary  until  the  pain  abates.  The  following  table  from  Holt 
gives  the  dose  of  the  opiates  most  useful  with  young  children: 


I  month. 

3  months. 

I  year. 

5  years. 

Paregoric    mi 

mii 

mv  to  X 

mxxx  to  xl 

Deodorized  tine,  m    1/20 

m   i/io 

m    |to^ 

m    2  to  3 

Dover's   Powder  gr  1/20 

gr  i/io 

grs  -1  to  i 

grs  2  to  3 

Morphine    gr  i/iooo 

gr  1/600 

grs 1/200 

gr  1/30  to  1/20 

Codeine    gr  1/300 

gr  1/200 

gr    1/60 

gr  i/io  to  1/8 

Used  hypodermically,  the  effects  of  morphine  are  more  prompt 
and  more  powerful,  and  caution  should  be  used  and  the  dose  les- 
sened. In  case  of  great  pain,  more  may  be  used  than  under  ordi- 
nary conditions.  But  always  time  should  be  given  for  effects  to 
subside  before  repeating  the  dose.  The  condition  of  the  patient 
as  to  expression  of  countenance,  attitude,  color,  the  urine,  stools, 
pulse,  and  temperature  should  be  carefully  watched,  for  the  child, 
even  less  than  the  adult,  notices  his  own  functions  and  symptoms, 
and  no  surgeon  should  wait  for  any  patient  or  nurse  to  make  the 
first  discovery  of  untoward  signs.  The  temperature  may  go  below 
normal  at  the  close  of  the  operation,  notwithstanding  that  artifi- 
cial heat  has  been  used,  but  if  pulse  and  respiration  remain  good, 
and  especially  if  there  has  not  been  great  blood  loss,  reaction  comes 
quickly  and  may  go  to  the  other  extreme,  giving  a  rise  of  temper- 
ature of  one,  two  or  three  degrees  within  twenty-four  or  thirty-six 
hours  and  then  subsiding.  This  aseptic  or  reactive  fever,  which 
comes  promptly,  occasions  little  alarm.  It  is  thought  to  be  due  to 
the  absorption  of  the  nucleins  and  albumoses  occasioned  by  the 
wound.  But  a  fever  that  comes  later,  after  the  first  day  succeeding 
the  operation — that  comes  with  a  chill  or  with  a  slow  rise — may 
mean  mischief.  It  may  be  due  to  wound  infection,  or  to  bronchitis 
or  pneumonia  or  nephritis,  or  one  of  the  exanthemata,  tonsilitis  or 
diphtheria,  or  to  autointoxication  from  the  intestinal  tract.  Espe- 
cially if  the  fever  is  accompanied  by  a  furred  tongue,  foul  breath,  a 
disturbed  or  distended  abdomen,  and  loss  of  appetite  or  a  morbidly 
craving  appetite,  an  active  laxative  may  clear  the  situation.  With 
children  the  chances  of  wound  infection  are  greater  than  with 
adults,  the  danger  of  hypostatic  pneumonia  less,  but  of  food  pneu- 


EXAMINATION,    CASE-TAKING    AND    GENERAL    SUBJECTS     53 

monia  ( ?),  the  exanthemata,  diphtheria,  or  digestive  disorder  more. 
Young  patients  demand  food  and  can  usually  take  food  sooner 
after  operation  than  adults.  An  infant  will  sometimes  be  nursed 
by  its  mother  almost  immediately  after  awakening  from  the  anes- 
thetic and  show  no  bad  result.  A  child  will  often  be  on  "  soft 
diet,"  or  nearly  on  "  full  tray  "  on  the  next  day  after  the  operation, 
unless  it  be  a  cleft  palate  or  abdominal  case  or  there  be  other  special 
caution  necessary.  In  fact,  there  seems  to  be  an  almost  incessant 
demand  for  nutrition  by  the  child's  tissues,  and  wounds  will  not 
heal  or  even  remain  aseptic  unless  the  nutrition  is  assiduously  kept 
up.  If  food  cannot  be  given  by  the  stomach,  rectal  feeding  should 
be  promptly  resorted  to  in  the  operated  case,  lest,  even  if  collapse 
do  not  result,  recovery  will  be  jeopardized  or  retarded. 

If  the  nature  of  the  wound  and  its  dressings  will  admit,,  the 
young  patient '  should  sometimes  be  taken  up  in  the  arms  of  the 
nurse ;  at  any  rate  its  position  should  be  changed.  While  not  so 
prone  to  hypostasis  or  bedsores,  this  is  useful.  With  infants  and 
young  children  a  certain  amount  of  "  mothering "  seems  to  be  a 
necessity.  Without  it  they  become  apathetic  and  give  up  the  fight 
for  life. 

An  abundance  of  fresh  air  and  sunlight  should  be  provided. 
Because  children's  beds  are  small  is  no  reason  why  more  of  them 
should  be  crowded  into  a  ward.  Too  many  people  think  any  little 
corner  will  do  for  the  child's  bed.  There  is  no  class  of  patients 
who  so  promptly  fade  and  languish  when  deprived  of  air  and  sun- 
light, and  none  will  respond  so  quickly  to  their  health-giving 
influence. 

LAVAGE,    GAVAGE    AND    RECTAL    FEEDING 

Lavage  and  gavage  may  be  unfamiliar  to  the  surgeon,  and  a 
short  description  will  be  presented  here.  Lavage  may  be  called 
for  in  case  of  ingestion  of  poison  or  of  prolonged  vomiting  after 
anesthesia.  No  especial  pump  or  suction  apparatus  is  necessary. 
A  soft  catheter  of  the  caliber  of  the  child's  index  finger,  attached 
by  a  piece  of  glass  tubing  to  two  or  three  feet  of  flexible  rubber 
tubing,  connected  with  a  funnel  and  a  pitcher  to  pour  the  solu- 
tion from,  comprise  the  apparatus.  Sterile  water,  normal  salt  solu- 
tion, or  solution  of  sodium  bicarbonate,  or,  in  case  of  poisoning,  an 
antidote,  are  the  fluids  used.  The  patient  is  usually  sitting,  but  may 
be  reclining.  Infants  require  no  mouth-gag ;  older  children  generally 
do.  The  patient's  hands  should  be  restrained.  The  length  of  tube 
required  to  reach  from  the  lips  to  the  stomach  can  be  measured  oflf 
by  the  eye.  It  should  not  include  the  bit  of  glass  tubing.  An 
assistant  holds  the  funnel  and  pitcher  above  the  patient's  head.  The 
surgeon  depresses  the  tongue  with  his  left  index  finger  and  passes 


54  SURGICAL   DISEASES    OF   CHILDREN 

the  tube  rapidly  through  the  pharynx  and  into  the  stomach.  The 
funnel  is  then  elevated  to  allow  the  air  or  gas  to  escape  from  the 
stomach,  and  then  lowered  to  allow  any  fluid  contents  to  siphon  off. 
A  few  ounces  of  the  solution,  warmed  to  loo  or  no  degrees  F., 
are  then  poured  into  the  stomach  and  then  allowed  to  siphon  off  by 
lowering  the  funnel,  and  this  process  repeated  until  the  water  runs 
clear.  If  desired,  a  few  ounces  of  water  may  be  left  in  the  stomach 
to  allay  thirst,  if  retained.  In  removing  the  tube  it  should  be 
pinched  between  thumb  and  finger  to  prevent  dribbling,  and  with- 
drawn rapidly,  or  vomiting  will  follow. 

Gavage  is  forced  feeding  through  the  stomach  tube.  It  is 
done  in  the  same  manner  as  lavage,  and  usually  after  a  preliminary 
washing,  the  liquid  food,  partially  predigested  if  desired,  being 
left  in  the  stomach.  The  tube  should  be  pinched  and  rapidly  re- 
moved, and  the  mouth  held  open  for  a  moment  to  prevent  gagging. 
If  the  food  is  regurgitated,  more  can  be  introduced  at  once.  Nasal 
feeding  is  done  in  the  same  way,  excepting  that  the  tube  is  passed 
through  a  nostril.  It  has  the  advantage  of  avoiding  gagging.  It 
is  useful  in  some  cases  of  injury  or  operation  upon  the  mouth  or 
jaws.  These  methods,  one  or  the  other,  are  useful  whenever,  for 
any  reason,  the  child  cannot  or  will  not  swallow  food,  as  after 
tracheotomy,  intubation,  fracture  or  tumour  of  jaws,  hare-lip,  cleft 
palate,  and  the  like.  Both  the  stomach  washing  and  the  forced  feed- 
ing are  quite  safe  and  in  constant  use  among  pediatrists.  Rectal 
feeding  can  be  resorted  to  in  older  children,  almost  the  same  as  in 
adults.  But  in  infants  the  bowel  soon  becomes  irritated,  and,  after 
a  few  feedings,  rejects  the  enema. 

ANATOMY,    GROWTH,    AND    DEVELOPMENT 

"  It  is  worthy  of  remark,"  says  Guersant,  "  that  at  the  moment 
of  the  execution  of  the  operation  on  children  the  task  claims  from 
the  surgeon  the  most  exact  knowledge  of  anatomy,  for,  the  region 
being  of  less  extent  and  the  spaces  smaller,  we  are  often  obliged  to 
limit  the  incisions  and  to  give  them  only  such  dimensions  as  are 
absolutely  necessary.  The  neck  of  a  child  of  two  years,  for  exam- 
ple, upon  whom  tracheotomy  is  to  be  performed,  does  not  allow  of 
the  same  field  for  action  as  in  the  adult.  The  incision  of  the  peri- 
neum in  a  patient  of  the  same  age  demands  more  care  on  the  part 
of  the  surgeon  in  the  performance  of  lithotomy.  We  should,  in 
short,  be  well  persuaded  of  a  fact,  of  which  many  persons  seem 
ignorant,  that  operations  are  more  difficult  in  children  than  at  a 
more  advanced  age."  These  words  of  a  famous  surgeon  are  true, 
not  only  because  of  the  small  size  of  the  anatomical  parts  in  chil- 
dren, but  because  of  many  peculiarities  in  their  anatomy  with  which 


EXAMINATION,    CASE-TAKING   AND    GENERAL    SUBJECTS    55 

it  is  necessary  to  be  familiar.  But  these  differences  and  peculiari- 
ties undergo  continual  changes  with  the  development  and  growth 
of  the  child,  and  cannot  be  adequately  described  in  a  general  way. 
They  will  be  presented  when  we  come  to  deal  with  particular 
organs  or  regions  as  they  appear  at  the  age  and  stage  of  develop- 
ment most  likely  to  need  the  surgeon.  However,  it  may  be  ob- 
served that  all  through  infancy  and  childhood  the  skin  is  softer, 
smoother,  and  freer  from  rugosities  and  wrinkles  than  in  the  adult; 
and  that  the  subcutaneous  cushion  of  fat  is  thicker  and  of  lighter 
hue,  and  gives  a  more  rounded  outline  to  the  figure.  But  fat  is  not 
found  abundantly  packed  about  the  internal  organs  nor  padding 
the  omentum  of  the  child.  The  fasciae  and  aponeuroses  are  well 
developed  at  an  early  age,  but  are  more  delicate  than  in  the  adult, 
and  stretch  and  yield  more  readily  to  force.  Therefore  the  fasciae 
do  not  so  certainly,  as  in  the  adult  subject,  determine  the  course 
of  a  burrowing  abscess.  The  muscles  are  not  only  smaller,  but 
their  tissues  are  softer,  and  this,  together  with  their  lack  of  inner- 
vation, renders  them  weaker  in  proportion  to  their  size  than  in  the 
adult.  The  bones  of  the  child  are  much  less  firm,  but  more  elastic, 
and  the  periosteum  thicker  and  more  vascular  and  much  more  easily 
peeled  from  the  bone  and  more  closely  attached  to  the  epiphysial 
cartilage  than  in  later  life.  All  the  blood-vessels  are  larger  in  pro- 
portion in  the  child  than  the  structures  they  supply  or  drain.  The 
superior  development  of  the  vascular  system  over  other  systems — ■ 
for  instance,  the  respiratory,  the  muscular,  and  the  digestive — is 
most  noticeable  at  or  soon  after  birth.  As  development  and  growth 
proceed  the  respiratory  system  becomes  more  able  for  its  duties, 
the  digestive  system  is  completed  by  the  addition  of  the  teeth  and 
the  elaboration  of  its  glandular  structures,  by  various  modifications 
in  its  tissues  and  in  its  forms  and  their  relation  to  other  anatomical 
parts.  The  locomotor  and  prehensile  apparatus  not  being  requisite 
to  early  life  in  the  present  environment  of  human  offspring,  are 
slower  to  develop.  The  brain,  after  waiting  for  the  development 
of  the  vascular,  the  respiratory,  and  the  digestive  systems,  proceeds 
rapidly  up  to  the  seventh  year.  The  nerves  are  of  large  size  in 
the  child  in  proportion  to  the  structures  they  innervate,  but  their 
large  size  does  not  indicate  great  force,  for  the  nerve  centers  are 
not  completely  developed.  Lastly,  the  generative  organs  remain  in 
a  comparatively  undeveloped  state  until  puberty  approaches,  when 
they,  together  with  all  the  structures  derived  from  the  epiblast,  in- 
cluding neoplasms  when  present,  display  a  great  impulse  of  develop- 
ment. 

The  delicacy  and  softness  of  all  the  tissues  in  the  young  makes 
them  Hable  to  extensive  injury  in  case  of  violence,  and  also  more  apt 
to  tear  out  under  undue  tension  of  the  surgeon's  sutures,  or  to  cut 


S6  SURGICAL   DISEASES    OF    CHILDREN 

through  if  his  ligatures  be  too  tightly  drawn  in  tying.  This  softness 
and  delicacy  should  be  borne  in  mind  when  applying  a  tourniquet, 
when  applying  the  taxis,  when  reducing  dislocations  or  fractures, 
using  an  osteoclast  or  employing  force  for  any  purpose,  even  when 
retracting  the  lips  of  a  w^ound  or  exploring  a  cavity. 

It  may  aid  the  surgeon's  observation  of  the  growing  child  to 
borrow  certain  measurements  from  the  artist.  The  ideal  figure  of 
an  adult  male  (artistic  ideals  are  copied  from  the  most  perfect 
specimens  of  the  species)  is  eight  heads  tall.  That  is,  the  whole  fig- 
ure, from  crown  to  sole,  is  eight  times  the  distance  from  the  level 
of  the  top  of  the  head  to  the  level  of  the  chin ;  and  the  central  point 
is  at  the  os  pubis.  In  the  infant  at  birth  the  w^iole  figure  is  four 
heads  tall,  and  the  point  midway  between  the  crown  and  sole  is 
at  the  navel.  At  two  to  two  and  a  half  years  old  (the  end  of  the 
period  of  infancy,  the  completion  of  the  first  dentition)  the  child 
is  about  five  heads  tall.  At  four  to  five  years  its  head  is  one-sixth 
of  its  whole  height.  After  the  sixth  year  (the  point  when  child- 
hood merges  into  youth),  growth  in  height  proceeds  more  slowly, 
so  that  it  is  not  until  the  fourteenth  year  that  the  figure  is  seven 
heads  tall.  Meanwhile,  owing  to  the  greater  proportionate  growth  of 
the  lower  half  of  the  figure,  especially  of  the  extremities,  the  cen- 
tral point  has  gradually  traveled  downw^ard  from  the  umbilicus  and 
approached  the  os  pubis.  During  adolescence — that  is,  from  pu- 
berty until  complete  development — the  figure  grows  about  one  head 
taller,  and  the  adult  type  is  attained. 

The  medical  profession  has  long  recognized  the  existence  of 
great  differences  in  height,  weight,  and  bodily  and  mental  develop- 
ment between  dift"erent  infants  and  children  of  the  same  chrono- 
logical age.  These  differences  are  not  merely  because  of  sex ;  they 
pertain  to  the  child's  anatomy,  physiology,  and  to  mental  and  moral 
characteristics,  and  they  obtain  at  all  ages  throughout  the  period  of 
development  to  the  adult.  In  other  words,  the  chronological  age 
of  the  child  by  no  means  indicates  accurately  his  or  her  age  from 
the  anatomical  or  physiological  point  of  view.  In  the  words  of 
Crampton,  whose  contributions  have  recently  drawn  attention  anew 
to  this  subject,  "  It  is  vastly  more  important  for  us  to  know  how 
far  a  child  has  developed,  and  what  he  is,  than  to  know  merely  how 
many  years  and  months  he  has  lived,  although  the  latter  fact  will 
always  have  a  relative  significance,"  and  he  formulates  the  proposi- 
tion that  physiological  age  should  be  taken  as  a  basis  of  all  record 
investigation  and  pedagogical,  social,  ethical,  or  medical  treatment 
of  children.  Rotch  has  recently  ^  presented  studies  looking  toward 
the  establishment  of  an  index  of  anatomical  or  physiological  age, 

1  Meeting  of  the  Section  on  Children,  Am.  Med.  Assoc,  Chicago,  June, 
1908.     Also  Rotch's  "  Living  Anatomy  and  Pathology,"   1910,  p.  49  ct  scq. 


EXAMINATION,    CASE-TAKING    AND    GENERAL    SUBJECTS     57 


Table  Showing  Average  Weight,  Height,  and  Circumference 

OF  the  Head  and  Chest  from  Birth  to  the 

Sixteenth   Year.      (Boas.) 


AGE 

Birth. 


6  mos. 


12  mos. 


iS  mos. 

2  years. 

3  years. 

4  years. 

5  years. 

6  years. 


7  years. 

8  years. 

9  years. 


10  3'ears. 

11  years. . 

12  years. , 

13  years. 

14  years. 

15  years. 

16  years.  . 


WEIGHT  height  CHEST  HEAD 

SEX  Pounds      Kilos  Inches      Cm.    Inches    Cm.    Inches    Cm. 

Boys 7.55        3.43  20.6 

Girls 7.16       3.26  20.5 


52.5     13.4     34.2     13.9     35.5 
52.2     13.0     23.2     13.5     34-5 


Boys. 
Girls. 


16.0 
15-5 


Boys 20.5 

Girls 19.8 

Boys 22.8 

Girls 22.0 

Boys 26.5 

Girls 25.5 

Boys 31.2 

Girls 30.0 


7.26  25.4 

7.03  25.0 

9.29  29.0 

8.84  28.7 

10.35  30.0 

9.98  29.7 

12.02  32.5 

11.56  32.5 

14-14  35-0 

13-60  35.0 


64.8  16.5  42.0  17.0  43.5 

63.6  16.1  41.0  16.6  42.2 

73.8  18.0  45.9  18.0  45.9 

73.2  17.4  44.4  17.6  44-6 

76.3  18.5  47.1  18.5  47.1 
75.6  18.0  45.9  18.0  45.9 

82.8  19.0  48.4  18.9  48.2 

82.8  1S.5  47.0  18.6  47.2 


89.1     20.1     5 1. 1 
89.1     19.8     50.5 


19.3     49.0 
19.0     48.4 


Boys 35.0     15.87     38.0 

Girls 34.0     15.41     38.0 


5.7     20.7     52.8     19.7     50-3 
S.7     20.5     52.2     19.5     49.6 


Bo3rs 41.2  18.71  41.7  106.0  21.5  54.8     20.5     52.2 

Girls 39.8  18.06  41.4  105.3  21.0  53.5     20.2     51.3 

Boys 45.1  20.48  44.1  112. o  23.2  59.1 

Girls 43.8  19.87  43.6  110.9  22.8  58.3 

Boys 49.5  22.44  46-2  1 17.4  23.7  60.6 

Girls 48.0  21.78  45.9  116.7  23.3  59.5 

Boys 54.5  24.70  48.2  122.3  24.4  62.2 

Girls 52.9  24.01  48.0  122. 1  23.8  60.8 

Boys 60.0  26.58  50.1  127.2  25.1  63.9 

Girls 57.5  26.10  49.6  126.0  24.5  62.5 

Boys 66.6  30.22  52.2  132.6  25.8  65.6     21.0     53.5 

Girls 64.1  29.07  51.8  131. 5  24.7  63.0     20.7     52.8 


Boys. 
Girls . 


72.4     32.83     54.0     137-2     26.4     67,2 
70.3     31-87     53-8     136.6     25.8     65.8 


Boys 79.8  36.21  55.8  141. 7  27.0  68.8 

Girls 81.4  36.90  57.1  145.2  26.8  68.3 

Boys 88.3  40.04  58.2  147.7  27.7  70.6 

Girls 91.2  41.36  58.7  149.2  28.0  71.3 

Boys 99.3  45.03  61.0  155. 1  28.8  73.3 

Girls 100.3  45.50  60.3  153.2  29.2  74.1 

Boys 110.8  50.26  63.0  159.9  30.0  76.6 

Girls 108.4  49.17  61.4  155.9  30.3  76.8 

Boys 123.7  56.09  65.6  166.5  3'i-2  79-2 

Girls 113.0  51.24  61.7  156.7  30.8  78.8 


21.8     55-5 
21.5     54-8 


58  SURGICAL  DISEASES  OF  CHILDREN 

based  upon  the  development  of  the  wrist  joint,  the  appearance  of 
the  centers  of  ossification  in  the  unciform  bone,  the  epiphysis  of  the 
lower  end  of  the  radius,  the  cuneiform,  the  semilunar,  etc.  Whether 
it  will  be  proven  that  the  entire  anatomy  of  the  child  and  the  stage 
of  the  development  of  its  circulatory  and  digestive  systems  and 
its  brain — in  short,  of  all  its  bodily  and  mental  organs  and  func- 
tions— corresponds  to  and  can  be  determined  by  the  state  of  one 
joint,  or  even  of  all  the  epiphyses  or  all  the  connective  tissues,  re- 
mains to  be  demonstrated. 

Recent  investigations  ^  upon  200  subjects  varying  in  age  from 
infancy  to  adolescence,  and  in  mental  capacity  from  idocy  to 
brilliancy  warrant  the  belief  that  the  ossification  of  the  wrist  of  an 
individual  is  not  an  exact  index  of  the  state  of  ossification  of  the 
remainder  of  the  skeleton.  That  while  age,  height,  and  weight  in- 
crease in  general  with  advance  in  carpal  ossification  there  are  so 
many  exceptions  found,  in  both  sexes,  as  to  make  classification  by 
such  a  method  impracticable  for  regulating  the  life  of  the  child. 
There  was  found  no  relation  between  degree  of  carpal  development 
and  quality  of  mind.  The  relation  between  the  stages  of  puberty 
and  those  of  carpal  ossification  is  too  indefinite  to  be  used  as  an 
index  of  physiologic  development.  Carpal  development  when  ob- 
served at  intervals  and  considered  with  other  factors  may  aid  in 
estimating  the  rapidity  of  growth  of  the  skeleton. 

The  changes  that  take  place  in  the  child  at  puberty  are  well 
worthy  of  our  attention.  Crampton's  tables  ^  show  that  at  charac- 
teristic ages  the  sexually  mature  are  more  than  33  per  cent,  heavier, 
10  per  cent,  taller,  and  33  per  cent,  stronger  than  the  immature. 
Yet  the  instability  of  the  physical  and  mental  organization  at  this 
period — the  increased  morbidity  without  increased  mortality — 
should  be  borne  in  mind  by  the  surgeon. 

Newer  applications  of  the  idea  of  considering  anatomical  or 
physiological,  rather  than  chronological,  age,  are  more  needed  in 
pedagogical,  social,  and  economic  studies,  where  they  have  been 
neglected,  than  they  are  in  medical  or  surgical  lines,  where  the 
underlying  principle  has  been  studied  with  relation  to  normal  devel- 
opment and  in  connection  wnth  achondroplasia,  cretinism,  rachitis, 
syphilis,  and  other  conditions  of  faulty  development  or  disease,  as 
well  as  traumatism. 

For  the  surgeon  the  study  of  the  development  of  the  joints  and 
bones  will  always  possess  special  interest  on  account  of  frequent 
injuries  and  diseases  of  these  structures  and  the  definite  relationhip 
between  their  anatomical  and  physiological  structure  and  condition 
and  their  pathological  processes. 

1  Long  and  Caldwell.     Am.  Jour.  Diseases  of  Children,  Vol.  i.  No.  2.  Feb., 
I911.  2  Pediatrics,  June,   i90§, 


CHAPTER  II 

GENERAL     SURGICAL     PATHOLOGY     OF     THE 
DEVELOPING    PERIOD 

Malformations — Giantism — Acromegaly  —  Achondroplasia  — 
Tumors  in  Infancy  and  Childhood — Retention  Cysts. 

The  departures  from  the  normal  state  which  may  appropriately 
be  considered  in  a  treatise  on  pediatric  surgery  may  be  divided,  from 
the  clinical  standpoint,  into  three  classes.^  In  the  first  class  may  be 
placed  all  those  abnormal  conditions  which  are  found  exclusively 
in  children.  To  this  class  belong  the  congenital  malformations,  the 
obstetrical  injuries,  including  meningeal  hemorrhage  and  Erb's  and 
facial  paralyses,  dislocations,  cranial  and  other  fractures,  the  early 
evidences  of  hereditary  syphilis,  separation  of  the  epiphyses ;  croup, 
with  its  frequent  demand  for  aeroporotomy ;  rickets,  with  its  numer- 
ous deformities  requiring  surgical  attention ;  eneuresis,  pyloric  sten- 
osis of  infants,  hydrocephalus,  cancrum  oris  and  noma,  certain  her- 
nise  and  hydroceles,  and  certain  varieties  of  tumor.  In  the  second 
class  may  be  placed  all  those  surgical  affections  which,  although 
not  found  exclusively  in  children,  practically  belong  to  the  surgical 
diseases  of  childhood  because  of  their  far  greater  frequency  at  this 
time  of  life.  To  this  class  belong  hemophilia,  intussusception,  pro- 
lapse of  the  rectum,  hip-joint  disease,  tubercular  dactylitis,  post- 
nasal adenoids,  enlarged  tonsils,  foreign  bodies  in  the  nose  and  ear, 
and  cervical  adenitis. 

If,  now,  we  include  in  the  third  class  all  those  diseases  which, 
when  occurring  in  the  child,  present  different  phenomena,  run  a 
different  course,  reach  a  different  termination,  or  react  differently 
to  treatment  from  the  same  diseases  when  occurring  in  the  adult, 
we  will  find  upon  our  list  not  only  the  fractures  and  dislocations 
and  empyema,  but  the  infections  and  nearly  the  whole  list  of  surgi- 
cal ailments,  even  if  we  do'  not  mention  orthopedic  cases  and  numer- 
ous eye  and  skin  affections  which  properly  should  be  included. 

Obviously,  if  I  were  to  endeavor  to  assort  into  a  pathological 
classification  and  to  trace  the  structural  and  functional  changes  pre- 
sented in  all  these  abnormal  states  and  to  compare  them  in  their 
resemblances  and  in  their  differences  with  like  states  when  there 

1  This     classification     was     suggested     to     me     by    the    perusal     of    T. 
Holmes, 

59 


6o  SURGICAL   DISEASES    OF    CHILDREN 

are  such  presenting  in  the  fully  developed  organism,  this  chapter  and 
this  book  would  extend  to  inordinate  size.  It  must  suffice  for  the 
present  purpose  to  present  a  brief  account  of  the  more  common 
among  them,  in  some  of  their  phases  in  relation  to  surgical  pedi- 
atrics. 

MALFORMATIONS 

Malformations  may  take  their  origin  in  an  error  of  develop- 
ment of  the  embryo  itself,  or  in  some  fault  of  its  environment  dur- 
ing intrauterine  life.  In  some  instances  of  the  first  class  of  cases 
the  cause  is  still  more  remote  than  the  individual  embryo,  having 
been  present  in  the  ovum  or  spermatozoon  and  communicated 
through  the  mysterious  force  of  heredity  or  the  laws  of  reversion 
or  atavism.  As  conspicuous  instances  of  inherent  error  of  develop- 
ment, will  be  cited  malformations  occurring  through  failure  in 
union  of  the  visceral  arches  of  the  head  and  face  and  the  dorsal  and 
ventral  plates,  resulting  in  hare-lip  and  cleft  palate,  extroversion  of 
the  bladder,  hypospadias,  epispadias,  exomphalos,  branchial  fistulas, 
and  at  least  some  of  the  cases  of  cranial  meningocele  and  spina 
bifida.  Ano-rectal  imperforations  and  malformations  of  pharynx 
and  esophagus  manifestly  belong  to  the  same  general  class.  Here, 
also,  belong  the  cases  of  fetal  inclusion,  supernumerary  limbs,  as 
tripodism,  polydactylism,  the  dermoid  growths ;  at  least  some  of 
the  cases  of  deficiency  of  limbs,  club-foot  and  hand,  and  of  syndac- 
tylism, and  anomalies  of  the  muscular  system,,  transposition  of 
organs,  et  cetera. 

In  the  second  class,  in  which  malformation  was  acquired  by 
reason  of  surroundings  during  the  formative  period,  are  the  cases 
of  intrauterine  amputations  of  limbs  or  digits,  and  constrictions  by 
amniotic  bands ;  distortions  of  parts  caused  by  pressure,  as  in  at 
least  some  of  the  cases  of  clubfoot  and  of  genu-extrorsum  and  the 
like ;  and  dwarfing  or  suppression  of  a  limb  or  a  part,  such  as  the 
lower  end  of  the  radius  or  ulna,  causing  clubhand.  Of  the  causa- 
tion of  perhaps  the  majority  of  cases  of  clubfoot  and  many  other 
deformities,  there  is  at  present  no  satisfactory  explanation. 

Some  phases  of  this  subject  will  be  touched  upon  in  the  section 
on  Teratoma,  in  the  chapter  on  Tumor  Growth. 

A  classification  descriptive  of  the  malformations  has  sometimes 
been  used,  arranging  them  in  three  classes,  according  to  whether 
there  was  (a)  excess  of  development,  (b)  deficiency  of  develop- 
ment, or  (c)  distortion  of  parts.  Such  a  grouping  need  not  be 
attempted  here,  but  a  description  of  such  malformations  as  have  a 
practical  surgical,  as  well  as  a  pathological,  interest  will  be  pre- 
sented. 

GIANTISM 

In  curious  contrast  with  the  normal  growth  and  development 


SURGICAL   PATHOLOGY   OF   THE    DEVELOPING    PERIOD      6i 

are  those  rare  conditions  in  which  gigantic  growth  takes  place. 
This  may  be  general  or  partial — that  is,  it  may  affect  the  entire  indi- 
vidual, or  only  certain  parts.  General  giant  growth,  which  is  sym- 
metrical and  complete,  is  very  rare.  In  most  cases  the  increased 
size  is  mainly  due  to  increased  length  of  the  long  bones.  There  is 
often  knock-knee,  or  infantilism — usually  a  head  of  only  average 
size,  with  very  ordinary  intelligence,  and  various  stigmata  of  degen- 
eration. The  giant  growth  usually  commences  about  puberty. 
Occasionally  supernumerary  organs,  accessory  ribs,  etc.,  are  asso- 
ciated with  general  giantism. 

ACROMEGALY 

Acromegaly,  or  Marie's  disease,  is  closely  allied  to  giantism. 
It  presents  giant  growth  of  hands  or  feet,  and  sometimes  also  of 
the  forearms  and  legs,  or  of  some  of  the  bones  of  the  face,  espe- 
cially the  lower  jaw  and  the  bridge  of  the  nose.  In  the  extremities 
the  overgrowth  of  the  bones  is  not  as  great  in  proportion  as  that 
of  the  soft  parts.  A  marked  peculiarity,  and  one  which  distin- 
guishes acromegaly  from  giantism,  is  that  the  joint  spaces  are  very 
wide.  Osteophytes  are  apt  to  appear  in  the  neighborhood  of  the 
joints.  Of  the  special  sense  organs  the  eye  suffers  most  in  acro- 
megaly. Pressure  on  the  chiasm  produces  optic  neuritis,  exophthal- 
mos, and  narrowing  of  the  vision  fields,  the  degree  of  impairment 
varying  with  the  amount  of  pressure,  which  may  result  in  complete 
blindness.  Enlargement  of  the  pituitary  body  and  disease  of  the 
thyroid  are  reported  in  connection  with  acromegaly,  but  the  pathol- 
ogy of  the  condition  is  obscure.  It  is  not  to  be  confounded  with 
elephantiasis,  nor  with  enlargements  in  connection  with  the  lym- 
phatic or  the  vascular  systems.  Hemihypertrophy  of  the  body  or 
of  other  parts  has  been  described.  (6) 

ACHONDROPLASIA 

Strikingly  different  from  the  condition  of  giantism  is  achon- 
droplasia, also  called  chondro-dystrophia  fetalis,  and,  unfortu- 
nately, fetal  rickets.  It  should  not  be  confused  with  rickets,  nor 
yet  with  hydrocephalus,  nor  cretinism.  As  its  name  indicates,  it 
is  a  disorder  of  cartilage  growth.  This  affects  the  primary  carti- 
lage, which  should  begin  ossification  early,  but  causes  early  cessa- 
tion in  its  growth  and  a  premature  ossification.  It  does  not  affect 
those  cartilages  which  normally  remain  cartilaginous  until  late  in 
fetal  life,  and  it  does  not  affect  those  parts  of  the  skeleton  which 
are  developed  in  membrane.  Thus  the  vertebrae  and  the  flat  bones 
escape,  while  the  long  bones  and  the  base  of  the  skull  are  dwarfed. 
The  bones  of  the  extremities  never  attain  length,  but  grow  in  thick- 
ness and  flare  widely  and  abruptly  at  the  joints.    They  do  not  bow 


62  SURGICAL   DISEASES    OF   CHILDREN 

as  in  rickets,  and  in  rickets  the  flaring  is  graduaL  The  dwarfing 
of  the  base  of  the  skull,  with  continued  growth  of  the  vault,  pro- 
duces the  peculiar  depression  in  the  region  of  the  e3-es  and  bridge 
of  the  nose,  with  the  expanded  and  overhanging  forehead  character- 
istic of  these  curious  dwarfs.  At  birth  the  upper  and  lower  extrem- 
ities are  very  short,  perhaps  less  than  half  the  normal  length ;  while 
the  head  is  large,  maybe  an  inch  or  two  larger  than  normal,  and 
appears  still  more  so  on  account  of  its  peculiar  shape.  The  belly 
is  large,  and  the  skin  has  the  appearance  of  being  altogether  too 
large,  resting  in  folds  at  the  flexures  of  the  extremities.  The  fin- 
gers are  short,  of  nearly  equal  length  and  each  bent  slightly  out- 
w^ard  at  its  middle,  giving  the  so-called  "  trident  hand."  The  infant 
may  be  born  dead  or  may  die  soon,  or  may  survive  and  even  live 
to  old  age.  Generally  the  babe  develops  slowly,  both  physically  and 
mentally.  Dentition  is  late,  closure  of  the  fontanel  especially  late, 
perhaps  in  the  fourth  or  fifth  year.  Walking  is  delayed  until  the 
third  or  fourth  year.  The  muscles  appear  weak  and  the  tendons 
and  ligaments  loose.  Later,  bowing  of  the  long  bones  may  appear. 
In  adult  life  great  muscular  strength  may  be  developed.  The  men- 
tal condition  remains  backward,  but  not  idiotic.  Dwarfs  of  this 
class  were  formerly  often  employed  as  court  jesters,  on  account  of 
their  odd  appearance  and  usual  amiable  humor.  The  adults  have 
normal  sexual  power.  Achondroplasia  is  not  regarded  as  a  trans- 
missible disease.  In  case  of  pregnancy  of  a  woman  thus  affiicted, 
Cesarean  section  is  usually  necessary.  No  treatment  for  achon- 
droplasia avails. 

TUMORS  IN  INFANCY  AND  CHILDHOOD 

One  need  not  deny  the  possibility  that  some  infectious  agents 
or  animal  parasites  as  yet  unknown  may  be  the  causes,  primary  or 
secondary,  of  certain  forms  of  tumor,  although  the  proof  of  either 
of  these  theories  has  not  yet  been  produced.  Neither  need  one  repu- 
diate the  evidence  of  Virchow  and  his  followers  that  without  unus- 
ual irritation  some  tumors  never  would  come  into  existence,  and 
others  never  would  change  from  benign  to  malignant,  although  it 
is  also  evident  that  there  must  be  a  predisposing  condition  of  the 
cells  or  tissues  which  determines  their  peculiar  behavior  when  the 
irritation  is  applied. 

Nor  should  one  refuse  to  believe  if  proof  were  adduced  that 
either  an  endogenous  infection  or  a  toxemia  produced  within  the 
system  excites  the  abnormal  cell-multiplication,  which  results  in  a 
neoplasm. 

In  using  in  this  section  a  modification  of  Cohnheim's  classi- 
fication of  tumors  and  definitions  resulting  from  it,  it  is  not  assumed 
that  his  theory  of  tumor  formation  through  defective  develpment 


SURGICAL   PATHOLOGY   OF   THE   DEVELOPING   PERIOD      63 

satisfactorily  explains  all  varieties  of  tumor,  nor  why,  after  lying 
dormant  during  a  long  time,  embryonal  rests  proceed  to  proliferate. 

There  is  no  explanation  or  theory,  neither  among  those  purely 
speculative  nor  among  those  deduced  from  experiment  or  clinical 
or  laboratory  study,  which  is  satisfactory  and  applicable  to  all  cases, 
and  consequently  there  is  no  satisfactory  classification. 

Certain  it  appears  that  Cohnheim's  theory  not  only  contains  a 
good  deal  of  truth,  but  that  it  lends  itself  well  to  the  classification 
and  description  necessary  in  the  teaching  of  science. 

I  know  of  no  recorded  observations  more  interesting  and 
instructive,  more  illuminating  to  the  subject,  than  those  of  Cohn- 
heim  and  Maas  with  periosteal  grafts.  Small  bits  of  periosteal  tis- 
sues were  set  adrift  in  the  jugular  veins  of  animals.  At  intervals 
of  weeks  or  months  later  the  animals  were  killed  and  the  experi- 
menters found,  as  they  had  expected,  that  the  grafts  had  lodged  as 
emboli  in  the  smaller  branches  of  the  pulmonary  artery  and  had,  true 
to  their  inherent  genetic  nature,  produced  bone.  The  size  of  each 
piece  of  bone  was  limited  to  the  size  of  the  lumen  of  the  vessel  in 
which  the  graft  was  lodged,  and  when  sufficient  time  had  elapsed 
the  bone  was  entirely  removed  by  absorption.  Leopold,  working 
with  Cohnheim,  made  observations  equally  valuable.  They  placed 
grafts  of  mature  tissue  in  the  anterior  chamber  of  the  eye  and  peri- 
toneal cavity  of  rabbits  and  noted  the  time  of  their  growth  to  ma- 
turity and  their  subsequent  removal  by  absorption.  They  also 
found  that  embryonic  tissue  taken  from  fetuses  and  transplanted  in 
the  same  way  showed  remarkable  vitality  and  power  of  growth — 
very  much  greater  than  that  of  mature  tissue.  Grafts  of  fetal  car- 
tilage increased  two  or  three  hundred  per  cent,  becoming  minia- 
ture enchondromata,  and  resisted  the  absorptive  processes  of  the 
surrounding  tissues  for  several  months. 

These  experiments  demonstrate  the  genetic  fidelity  of  cells, 
the  astonishing  vital  force  in  embryonic  cells,  and  also  they  show 
the  important  fact  of  a  physiological  resistance  which  normal  cells 
possess  against  the  encroachment  of  abnormal  growths. 

It  is  easy,  after  following  the  steps  of  these  experiments,  to 
form  a  mental  picture  of  a  matrix  of  superfluous  embryonic  cells 
belonging  to  the  epiblast  or  the  hypoblast  or  the  mesoblast,  and 
either  remaining  in  their  proper  situation  or  accidentally  trans- 
planted during  the  arrangement  of  the  folds  of  the  blastodermic 
layers — but  arrested  in  their  development  and  lying  dormant,  while 
the  cells  all  around  them  continue  active  and  go  on  with  the  devel- 
opment of  the  individual. 

A  tumor  is  a  localized  erratic  growth  from  just  such  an 
arrested  matrix  of  embryonic  cells  or  degenerate  cells.  It  differs 
from  an  hypertrophy  in  that  the  latter  is  a  numerical  increase  of 


64  SURGICAL   DISEASES    OF    CHILDREN 

tissue  elements  maintaining  the  structure  and  shape  of  the  type  of 
the  part  or  organ  affected.  It  differs  from  inflammatory  enlarge- 
ment in  that  the  latter  results  from  the  presence  of  pathogenic 
organisms  or  their  toxins  and  is  the  effect  of  such  agents  upon  ma- 
ture cell-tissues. 

In  treating  of  the  subject  of  tumors  one  is  obliged  to  bear  also 
in  mind  the  subject  of  retention  cysts.  It  is  perhaps  as  difficult  to 
differentiate  some  of  them  structurally  as  clinically  from  true 
tumors.  They  are  not  true  tumors.  Retention  cysts  are  produced 
by  obstruction  in  the  natural  outlet  of  a  gland,  causing  retention  of 
its  secretion  or  excretion,  and  changes  in  the  wall  of  the  obstructed 
cavity,  and  oftentimes  of  the  adjacent  tissues,  by  the  dilatation  and 
pressure. 

We  will  leave  to  the  pathologists  to  decide  whether  the  matrix 
of  embryonic  cells  from  which  the  tumor  springs  is  always  of  fetal 
origin  or  may  be  post-natal — -produced  by  mature  cells  not  capable 
of  producing  cells  of  a  higher  type-— but  producing  degenerate  cells, 
incapable  of  normal  development  or  of  the  reproduction  of  cells  of 
normal  type. 

It  is  conceded  that  the  cell-type  and  structure  of  a  tumor 
depend  upon  the  germinal  layer  from  which  its  matrix  is  derived, 
and  it  is  probable  that  the  character  of  the  tumor  depends  not  only 
upon  the  layer,  but  upon  the  stage  at  which  its  embryonic  cells  were 
arrested.  (7) 

The  classification  of  tumors  which  adheres  most  strictly  to 
their  origin  in  the  germinal  layers  is  that  of  Senn,^  who  exceeds 
Cohnheim  in  his  strict  application  of  this  theory,  and  whose  classi- 
fication has  the  merit  of  covering  the  ground  in  a  comprehensive 
and  comprehensible  manner. 

Reviewing  now  the  varieties  of  tumor  found  in  infants  and 
children,  we  will  begin  with  the  Fibroma. 

Fibroma. — These  benign  tumors,  the  type  of  the  connective 
tissue  tumors,  occur  anywhere  that  there  is  connective  tissue.  Pig- 
mental moles  are  fibromata  and  are  usually  congenital.  They  are 
prone  to  undergo  change  into  sarcom.a  or  carcinoma.  Fibromata 
may  be  single,  and  in  one  variety  extremely  painful ;  or  may  be 
multiple  and  appear  by  hundreds  as  small,  painless,  movable  nodules 
in  the  connective  tissue  immediately  beneath  the  skin,  or  as  shotty 
enlargements  along  the  nerve  trunks. 

Fibromata  are  sometimes  found  growing  in  the  naso-pharynx, 
most  often,  but  not  always,  springing  from  the  fibrous  covering  of 
the  basilar  process  of  the  occipital  bone. 

Fibro-angioma    and    fibro-sarcoma    are    not    unusual    in    this 

1 "  The    Pathology   and    Surgical   Treatment   of   Tumors,"   by    N.    Senn, 
to  which  the  writer  is  greatly  indebted  in  the  preparation  of  this  article. 


SURGICAL  PATHOLOGY  OF  THE  DEVELOPING   PERIOD        65 

region,  almost  always  in  boys  and  young  men  up  to  twenty-five. 
They  are  seldom  seen  under  the  tenth  year. 

Fibromata  may  grow  upon  the  tongue;  or  upon  the  alveolar 
process,  springing  from  the  periosteum  or  from  the  peridental 
membrane  and  called  fibrous  epulis  to  distinguish  them  from  carci- 
noma or  sarcoma  in  the  same  situation.  Fibrous  epulis  is  usually 
small,  dense,  smooth  in  outline,  and  has  a  pedicle  and  may  undergo 
ulceration.  It  bleeds  freely,  and  sometimes,  if  the  operator  cuts 
into  instead  of  around  the  base  of  the  tumor  before  detaching  from 
the  bone,  it  will  bleed  copiously. 

Fibroma  may  come  from  the  connective  tissue  of  the  alveolar 
process  itself  and  require  chisel  or  saw  for  its  removal. 

Fibromatous  tumors  of  the  heart  have  been  reported. 

Keloid,  which  is  a  variety  of  fibroma,  is  occasionally  found  in 
childhood,  and  cases  have  been  reported  as  occurring  congenitally, 
but  it  is  rare  before  puberty.  Vaccination  scars  and  pierced  ears 
are  sometimes  the  site  of  keloid. 

Etiology. — Fibromata  (including  sub- varieties  keloids  and 
desmoids)  are  among  those  tumors  apparently  caused  by  irritation 
or  trauma,  and  are,  perhaps  for  that  reason,  less  frequently  found 
in  infancy  or  childhood  than  in  adult  life  up  to  thirty-five  or  forty 
years.  However,  as  has  been  said,  they  do  occur  even  congenitally, 
either  alone  or  in  combination  with  adenoma,  lipoma,  or  angioma. 
According  to  Virchow,  there  may  be  an  hereditary  tendency  to 
fibroma. 

Symptoms  and  Diagnosis. — It  takes  its  origin  in  mesoblastic 
tissues.  It  is  smooth  in  outline  and  movable,  being  encapsulated. 
It  is  slow  of  growth.  The  more  rapidly  growing  and  more  vas- 
cular uterine  fibroma  is  not  a  tumor  of  childhood.  Fibroma  is 
painless  unless  connected  with  a  nerve  or  pressing  upon  it  or  in- 
flamed. It  is  less  apt  to  ulcerate  than  papilloma.  The  skin  cover- 
ing a  superficial  fibroma  is  more  apt  to  be  stretched  smooth  and 
thin,  atrophied,  than  the  covering  of  a  papilloma.  In  the  latter  the 
skin  grows  with  the  tumor. 

Prognosis. — The  amount  of  danger  from  fibroma  varies  with 
its  location,  as  to  whether  it  presses  upon  an  important  organ  or 
occludes  a  passage.  Another  source  of  danger  is  its  liability  to 
undergo  a  change  into  a  sarcoma,  especially  if  irritated  or  wounded. 
Keloid  is  apt  to  return  even  if  removed,  and  fibroid  polypus  may 
return. 

Treatment. — Easily  accessible  fibroma  should  always  be  re- 
moved, on  account  of  the  danger  of  the  transition  to  sarcoma.  In 
fibroma  of  internal  organs  the  risk  of  operation  has  to  be  considered 
and  may  make  it  more  prudent  to  refrain  from  operation.  But  if 
the    location    is    not    extemely    dangerous    the    tumor    should    be 


66 


SURGICAL   DISEASES    OF   CHILDREN 


removed.  Being  encapsulated,  it  should  be  enucleated,  but  if  ulcer- 
ated or  adherent,  as  a  result  of  inflammation,  it  should  be  excised. 

Myxoma. — Myxoma  may  be  congenital,  but  most  often 
appears  as  a  red,  pea-sized  or  cherry-sized  growth  at  the  umbilicus 
of  the  infant,  the  so-called  fungus  umbilici  or  polypus. 

A  rather  common  variety  is  polypus  of  the  rectum,  which  is  a 
soft  vascular  myxofibroma.  It  is  attached  to  the  wall  of  the  rectum 
by  a  pedicle,  and  the  pulling  upon  the  pedicle  may  cause  reflexly 


Fig.  I.  Myxo-fibroma  of  rectum.  The  tumor  may  be  located  a  finger 
length  within  the  sphincter;  but  is  sometimes  attached  so  low  and  with 
a  pedicle  so  long  that  it  may  appear  outside. 

great  irritability  of  the  bladder,  and  is  almost  certain  to  cause  fre- 
quent stools,  with  tenesmus,  pain  and  bloody  mucous  discharge. 
The  tumor  may  be  located  a  finger  length  within  the  sphincter, 
but  is  sometimes  situated  so  low  with  a  pedicle  so  long  that  it  may 
appear  outside  during  defecation,  as  seen  in  Fig.  i. 

Some  rectal  polypi  are  adenomata,  which  may  be  multiple. 
D'Arcy  Power  does  not  call  any  of  them  myxomata  but  true  adeno- 
mata, consisting  of  Lieberkiihn's  crypts,  grouped  irregularly  in  a 
stroma  of  fibrous  tissue.  But  he  says,  "  Cystic,  fibrous  and  dermoid 
polypi  occur  as  pathological  curiosities."  Pure  myxomata  occur  as 
polypi  of  the  nasal  cavities,  though  not  as  frequently  in  children 
as  from  puberty  on,  usually  following  catarrhal  inflammation  of 
long  standing.  They  are  generally  multiple,  pedunculated  and  trans- 
lucent, swell  in  damp  weather  or  on  taking  fresh  cold. 

Polypi  in  the  auditory  canal  also  occur  following  chronic  in- 
flammation with  moist  discharge. 

Myxo-lipoma  will  be  referred  to  under  the  heading  of  lipoma. 


SURGICAL   PATHOLOGY   OF   THE  DEVELOPING   PERIOD        67 

The  teratomata  often  have  myxomatous  tissue ;  and  myxosar- 
coma occurs  but  is  best  classed  with  the  sarcomata. 

Symptoms  and  Diagnosis. — Myxoma  is  much  hke  fibroma  in 
its  nature,  and  has  an  even  greater  tendency  to  change  into  sarcoma. 
It  is  soft,  fluctuating,  and  translucent,  and  when  located  on  the  sur- 
face is  small  and  sessile  or  pedunculated.  When  interstitial  in  its 
location  it  may  grow  large.  A  myxoma  grows  slowly,  and  if  it 
takes  on  rapid  growth  should  be  suspected  of  having  changed  to 
sarcoma,  and  specimens  taken  from  its  base  should  be  subjected  to 
microscopic   examination. 

Prognosis. — Pure  myxoma  is  benign,  but  its  liability  to  un- 
dergo   sarcomatous   transition    gives    it    a    doubtful    prognosis. 

Treatment. — A  myxoma  should  be  removed.  At  the  um- 
bilical site  the  tumor  may  be  snipped  off  and  the  w^ound  touched 
with  caustic.  Sometimes  it  is  sufficient  to  ligate  the  pedicle  and 
use  a  drying  powder,  as  oxide  of  zinc.  The  tumor  and  the  moist 
surrounding  surface  will  have  disappeared  in  a  few  days. 

Rectal  polypi  should  be  ligated  through  the  base  and  snipped 
ofif.  Although  cure  has  resulted  by  avulsion  performed  by  the 
sphincter  ani,  and  in  other  cases  by  the  finger  or  forceps  of  the 
surgeon,  simple  avulsion  is  not  a  good  plan.  Serious  hemorrhage 
has  occurred  from  the  artery  supplying  the  tumor ;  and  also 
incomplete  removal  has  been  followed  by  recurrence. 

Nasal  and  aural  polypi  are  removed  by  snare  or  forceps  or 
sharp  spoon.  Here  again  recurrence  may  follow  unless  the  work 
is  thoroughly  done,  the  basal  attachment  being  also  removed  and 
if  possible  the  instrument  followed  by  caustic. 

Lipoma. — Pure  lipoma,  lobulated,  circumscribed,  encapsulated, 
is  a  rare  tumor  in  childhood,  though  it  is  said  to  occur  even 
congenitally ;  but  fatty  tissue,  associated  with  nevus,  with  mus- 
cular, fibrous,  myxomatous,  cartilaginous  or  bony  tissue  or  with 
giantism,  or  with  congenital  sacral  tumors  resembling  spina  bifida, 
are  not  uncommon.  There  may  be  general  hypertrophy  of  fat, 
and  in  cretins  the  peculiar  enlargements  at  the  root  of  the  neck, 
sometimes  called  "  pseudo-lipoma."  Lipoma  is  the  most  innocent 
variety  of  tumor,  being  dangerous  only  from  its  size  or  position. 
Like  the  sucking  pads  of  infancy,  it  does  not  lessen  during  ema- 
ciation due  to  inanition. 

Treatment. — Treatment  of  lipoma  is  excision.  The  treat- 
ment of  combination  tumors  in  which  lipoma  forms  a  part  will 
be  mentioned  under  appropriate  heading.  General  hypertrophy 
of  fat  or  "  lipomatosis,"  and  the  fatty  enlargements  of  cretinism 
have  no  surgical  treatment. 

Enchondroma. — Of  the  innocent  growths  occurring  con- 
genitally or  in  infancy  and  childhood,  enchondromata  are  among 


68  SURGICAL   DISEASES   OF    CHILDREN 

the  most  common.  Chondroma  of  bone  ahiiost  ahvays  makes  its 
appearance  before  puberty.  Chondroma  in  the  region  of  the  first 
branchial  tract  is  more  apt  to  show  itself  after  puberty.  They 
may  grow  sub-periosteally,  or  as  frequently  from  the  interior  of 
the  short  long-bones.  A  favorite  site  is  the  phalanges,  which  they 
distort  badly.  They  are  apt  to  be  multiple,  perhaps  affecting  sev- 
eral or  all  of  the  fingers  of  one  or  both  hands.  They  may  appear 
in  the  parotid  gland,  in  the  testicle  or  the  ovary  or  upon  the  cranial 
bones. 

Hereditary  influence  is  evident  in  some  cases,  trauma  plays  an 
important  part  in  exciting  the  growth  of  the  chondromatous 
matrix,  and  the  rachitic  condition  predisposes  toward  if  it  does 
not  actually  produce  cartilaginous  tumors  of  bone.  Enchondro- 
mata  are  hard  unless  cystic  on  the  surface;  and  painless  unless 
pressing  on  a  nerve.  They  usually  grow  steadily,  and  slowly  but 
occasionally  are  rapid  in  growth,  simulating  malignancy  in  their 
rapid  increase,  as  in  the  noted  case,  reported  by  Paget,  of  a  little 
girl  who  had  enchondroma  of  the  upper  two-thirds  of  the  tibia 
which  reached  a  circumference  of  two  feet  in  eighteen  months. 
Usually  its  slow  growth  and  being  multiple  help  to  distinguish 
enchondroma  from  osteo-sarcoma.  When  unmixed,  enchondroma 
is  encapsulated.  A  strong  steel  needle  may  help  to  distinguish 
enchondroma  into  which  it  can  be  thrust,  from  osteoma,  which 
stops  the  needle  upon  its  surface. 

The  prognosis  in  pure  enchondroma  is  favorable  while  it  re- 
mains such ;  but  its  liability  to  transition  into  sarcoma  should  be 
borne  in  mind. 

Chondroma  of  bone  usually  ceases  to  increase  when  the  skele- 
ton has  attained  its  growth,  but  it  may,  when  situated  at  the  epi- 
physeal cartilage,  seriously  im.pair  joint  motion. 

However,  its  removal  may  prove  a  very  troublesome  matter  by 
implicating  the  joint.  A  pedunculated  tumor  can  be  extirpated; 
but  if  it  involve  the  whole  thickness  of  the  shaft  of  a  long  bone  it 
cannot  be  removed  without  amputation.  Enchondromata  spring- 
ing from  the  interior  of  long  bones  must  be  removed  from  their 
depths  or  they  may  recur. 

Enchondroma  of  the  parotid  gland  may,  after  attaining  a 
moderate  size,  cease  to  grow.  Its  proper  treatment  is  enucleation, 
great  care  being  taken  to  remove  all  the  tumor  and  to  avoid  injur- 
ing either  the  facial  nerve  or  the  duct  of  the  gland. 

A  small  enchondroma  of  the  testicle  or  ovary  may  be  removed, 
but  if  large,  castration  or  ovariotomy  is  indicated. 

Osteoma. — An  osteoma  is  a  tumor  composed  of  osseous  tissue 
which  may  be  either  compact  or  cancellous.  It  is  generally  com- 
posed of  cancellous  bone  covered  with  chrondromatous  or  myxo- 


SURGICAL   PATHOLOGY   OF  THE  DEVELOPING   PERIOD        69 

chondromatous  tissue.  Osteomata  occur  frequently  in  childhood, 
the  time  when  bone  growth  is  very  active ;  and  they  often  spring 
from  near  the  epiphyseal  line,  the  point  of  greatest  activity  in  the 
bone  growth. 

There  is  much  resemblance  between  the  osteoma  and  the  en- 
chondroma  and  frequent  mixtures  and  transitions  occur.  The 
osteoma,  like  the  enchondroma,  is  hard  to  distinguish  from  inflam- 
matory growth.  It  shows  hereditary  influence  or  a  predisposing 
cause,-  may  follow  irritation  or  traumatism,  is  painless,  apt  to  be 
multiple,  slow  of  growth  and  may  stop  growing  when  the  young 
patient  has  arrived  at  his  full  stature.  Osteoma  may  be  symmetri- 
cal on  the  two  sides,  different  members  of  the  same  family  or 
different  generations  may  have  the  same  bones  affected.  They 
spring  from  either  bone  or  cartilage  or  connective  tissue  near 
bone,  or  other  connective  tissue  or  serous  membrane,  or  testicle 
or  parotid,  A  favorite  site  is  the  upper  epiphyseal  line  of  the 
humerus. 

Pure  osteomata  are  innocent  and  do  not  produce  metastasis, 
but  may  require  removal  if  they  cause  pain  or  interfere  with  joint 
motion.     When  thoroughly  removed  they  do  not  recur. 

Myoma. — Rhabdomyoma  (composed  of  striated  muscular 
fibers)  is  so  rare  as  to  be  a  pathological  curiosity.  Nevertheless, 
a  number  of  writers  since  Zenker,  including  Cohnheim,  Marchand 
and  Eberth,  have  reported  cases.  When  rhabdomyoma  does  occur 
it  is  always  congenital.  It  usually  develops  in  connection  with  kid- 
ney or  testicle  and,  although  complex  in  structure,  when  benign,  is 
best  described  as  a  myoma,  as  that  issue  most  truly  indicates  its 
genesis. 

Myoma  and  myo-fibroma  have  been  found  in  the  heart  muscle. 
Rhabdomyoma  of  the  scrotum  has  been  reported  by  Rokitansky, 
and  another  case  by  Neumann,  in  the  testicle  of  a  boy  of  three 
and  one-half  years.  Striated  muscular  fibers  were  also  found  in  a 
tumor  of  the  parotid  in  a  boy  of  seven  years  by  Prudden.  They 
have  also  been  found  in  vesical  polypus  and  in  tumors  of  testicle 
and  ovary.  Striated  muscular  fibres  occur  more  frequently  in 
sarcoma,  and  are  best,  at  least  for  clinical  reasons,  classed  under 
that  heading. 

Leiomyoma  (composed  of  unstriped  muscular  tissue),  al- 
though of  much  greater  importance  to  the  surgeon  of  adult  life, 
seldom  presents  itself  to  the  child's  surgeon.  Myoma  of  the  uterus 
(so  common  and  so  important)  and  of  the  prostate,  practically 
belong  entirely  to  adult  life.  Myoma  of  the  uterus  has  never  been 
known  to  occur  congenitally,  and  it  is  stated  that  the  youngest 
patient  ever  known  with  that  disease  was  ten  years  of  age. 

Neuroma. — Ashby  and  Wright  report  the  case  of  an  eleven- 


70  SURGICAL   DISEASES    OF    CHILDREN 

year-old  girl  who  after  years  of  suffering  was  operated  upon  for  a 
neuroma  in  connection  with  the  posterior  tibial  nerve.  The  tumor 
reached  from  the  middle  of  the  leg  to  nearly  the  middle  of  the 
inner  side  of  the  foot.  The  tumor  and  nerve  were  inextricable, 
and  five  inches  of  the  latter  were  removed  with  the  tumor.  The 
result  was  a  good  recovery  without  sensation  in  the  foot.  Micro- 
scopically the  tumor  was  a  myxo-fabroma.  Nerves  could  be  traced 
for  some  distance  in  it  and  then  became  degenerated  and  lost. 

The  authors  state  that  this  is  the  only  neuroma  they  have  ever 
met  in  a  child,  and  we  know  theirs  has  been  a  large  experience 
with  children. 

This  "  neuroma,"  which  proved  to  be  a  myxofibroma,  seems 
to  be  a  fair  example  of  the  neuromas  reported.  They  are  very 
rare,  and,  after  all,  many  are  painful  myomas,  or  fibromas  or  myxo- 
mas connected  with  a  nerve  in  various  parts  of  the  body,  or  as  a 
bulbous  tumor  traversed  by  nerve  filaments  in  amputation  stumps. 

The  true  neuromata  are  apt  to  be  plexiform,  and  occupy  the 
side  of  the  face,  the  temporal  region,  the  ear  or  the  eyelid,  or  the 
neck,  where  they  can  be  felt  beneath  the  thin  skin  of  these  parts ; 
but  most  of  them  on  close  examination  are  composed  of  fibrous 
tissue  (springing  from  the  nerve  sheath)  in  which  the  nerves  are 
embedded. 

It  is  said  that  plexiform  neuromata  are  always  congenital; 
and  that  multiple  neurofibromata,  or  what  Virchow  called  "  gen- 
eral neuromatosis,"  involving  in  som.e  cases  nearly  all  the  nerves  in 
the  body,  almost  always  appear  in  children  or  young  adults. 

The  subcutaneous  painful  tumors,  the  amputation  neuromata, 
are  painful,  and  also  other  neuromata  if  they  press  upon  nerves. 
But  neuromata  can  exist  without  pain.  Numbness  may  or  may  not 
be  present.  A  neuroma,  excepting  the  plexiform  variety,  is  apt  to 
be  definite  in  outline  and  spindle-shaped,  its  long  axis  in  the  line 
of  a  nerve  trunk.  It  is  movable  and  encapsulated.  Multiple  neuro- 
fibromata are  painless  and  are  situated  upon  branches  of  nerves. 
A  plexiform  neuroma  somewhat  resembles  an  angioma  in  its  shape, 
but  can  be  differentiated  by  its  firmness  under  pressure,  and  re- 
maining the  same  when  the  vascular  trunks  of  the  part  are  pressed 
upon  or  rendered  vascular  by  position. 

Neuroma  is  of  itself  innocent,  but  may  undergo  transition  into 
sarcoma,  or  may  impair  the  health  by  pain  or  disable  a  part  by 
pressure  upon  the  nerve  supplying  it. 

Treatment. — Neuroma  if  troublesome  should  be  removed, 
otherwise  not.  The  painful  subcutaneous  neuroma  should  be  ex- 
cised ;  likewise  the  plexiform  neuroma.  Amputation  neuroma  when 
painful  should  be  excised,  together  with  the  old  scar  enclosing  it 
and  a  portion  of  the  old  nerve  to  which  it  is  attached.     Tumors 


SURGICAL  PATHOLOGY   OF  THE  DEVELOPING   PERIOD        71 

situated  upon  nerve  trunks  should  be  enucleated  without  injury  to 
the  nerve.  It  is  scarcely  ever  necessary  to  remove  any  portion  of 
the  nerve  trunk;  and  is  unjustifiable  unless  absolutely  unavoidable 
and  the  part  is  rendered  useless  by  the  presence  of  the  tumor. 
Multiple  neurofibromata  seldom  give  trouble  and  are  not  neces- 
sarily removed  unless  they  do. 

Lymphoma. — The  case  reports  and  even  the  text -books  are 
very  confusing  on  the  subject  of  lymphoma.  We  sometimes  see 
lymphoma,  lymphadenoma,  lymphosarcoma,  and  Hodgkin's  disease 
all  under  one  heading  as  if  they  were  synonymous,  and  again  even 
lymphadenitis  is  included. 

No  variety  of  tumefaction  is  so  extremely  common  in  chil- 
dren as  enlargement  of  the  lymphatic  glands.  Of  the  possible 
causes  of  lymphatic  enlargement  aside  from  lymphoma,  carcinoma 
(secondary,  of  course)  would  be  the  most  unusual  in  a  child.  Sar- 
coma would  be  less  rare ;  while  the  obscure  poisoning  of  leukemia 
and  pseudo-leukemia,  or  of  syphilis,  or  of  tuberculosis  producing 
a  chronic  adenitis,  or  by  pyogenic  microbes  producing  an  acute 
adenitis,  rank  as  common  causes  of  enlargement.  The  remote 
possibility  of  glanders  as  a  cause  of  lymphatic  enlargement  should 
be  borne  in  m.ind.  Differentiating  from  all  these  and  also  from 
lymphangioma  we  have  very  rarely  in  children,  more  commonly 
in  young  adults,  the  true  lymphoma,  a  benign  encapsulated  tumor 
composed  of  lymphatic  tissue  which  did  not  exist  before,  does  not 
result  from  any  infection  or  blood  disease  and  does  not  implicate 
adjacent  glands.  It  is  found  most  in  those  situations  where  the 
lymphatic  glands  are  most  numerous.  It  shows  neither  heat,  pain, 
redness  nor  tenderness ;  is  movable,  smooth  in  outline,  slow  in 
growth,  and  if  several  tumors  appear  at  once  they  increase  at  the 
same  rate. 

Treatment. — The  treatment  of  lymphoma  is  enucleation. 

Sarcoma. — Sarcoma  is  almost  the  only  form  of  malignant 
tumor  found  in  children.  It  is  not  as  frequent  as  with  adults,  but 
is  more  malignant;  that  is,  it  is  very  apt  to  grow  rapidly,  to  pro- 
duce early  a  profound  impression  on  the  general  health,  and  to 
recur  after  operation.  Males  are  more  frequently  affected  than 
females. 

Round-celled  sarcoma,  the  most  malignant  of  the  three  prin- 
cipal varieties,  is  apt  to  occur  in  connection  with  the  kidney, 
bladder,  testicle  or  ovary,  vagina,  brain  or  retina  (when  it  is  called 
glioma),  skin  and  subcutaneous  tissue,  lymphatic  glands,  fascia, 
periosteum  and  bone. 

The  spindle-celled  sarcoma,  often  called  the  recurrent  fibroid, 
ranks  second  in  degree  of  malignancy.  It  is  most  apt  to  spring 
from  fascia,  periosteum  or  bone. 


72 


SURGICAL  DISEASES    OF   CHILDREN 


The  giant-celled,  or  myeloid,  sarcoma,  which  is  apt  to  contain 
fibrous  or  osseous  elements,  is  the  least  malignant  of  the  three. 
It  is  likely  to  be  found  upon  the  articular  ends  of  the  long  bones 
and  upon  the  jaws.     The  epulis,  as  described  under  the  heading 

of  fibroid  tumor,  may 
contain  sarcomatous  ele- 
ments, and  possess  the 
characteristics  of  ma- 
lignancy. 

According  to  some 
authors,  sarcomata,  in- 
cluding gliomata  (sar- 
coma of  the  neuroglia), 
constitute  seventy-five 
per  cent,  of  all  the 
brain  tumors  of  chil- 
dren. This  figure  is 
too  high.  Sarcoma  of 
the  tongue  has  been  re- 
ported in  a  few  in- 
stances. Fibro-sarcomata 
are  found  in  the  naso- 
pharynx. 

Nsevi  sometimes  be- 
come sarcomatous.  Pri- 
mary sarcoma  of  the 
liver  and  pancreas  have 
been  reported.  In  both 
these  situations  the 
symptoms  and  diagno- 
sis are  so  difficult  that 
the  disease  is  well  ad- 
vanced before  a  diagno- 
sis can  be  made.  It 
runs  a  rapid  course  of 
a  few  weeks  to  a  fatal 
end.  Of  sixteen  cases 
in  patients  aged  from  five  to  eighteen  years  collected  by  Wm.  A. 
Edwards,  of  sarcoma  of  the  mediastinum,  all  proved  fatal  in  from 
three  weeks  to  ten  months. 

Sarcoma  of  the  kidney,  it  is  stated  on  the  authority  of  Doder- 
lein,  occurs  in  childhood  in  thirty-eight  per  cent,  of  all  cases  of 
sarcoma  of  kidney  at  all  ages.  It  is  generally  of  the  round-celled 
variety,   although  the   spindle-celled  do   occur,  and   some   contain 


Fig.  2.  Sarcoma  of  upper  end  of  humerus. 
Tumor  said  to  have  been  growing  three 
months.  Inoperable.  Patient  died  in  less 
than  two  months  after  this  photograph  was 
taken.     No  autopsy.     Girl  aged   12  years. 


SURGICAL  PATHOLOGY  OF  THE  DEVELOPING   PERIOD        y^ 

muscle  tissue,  both  striped  and  unstriped,  connective  tissue  in 
variety,  and  even  epithelium.  All  cases  not  operated  upon  end 
fatally,  the  average  duration  being  one  year.  The  tumor  is  usually 
painless,  smooth  and  rounded,  is  usually  solid,  may  be  so  soft  and 
vascular  as  to  give  pseudo-fluctuation;  may  be  cystic  and  give  real 
fluctuation ;  may  be  so  friable  as  to  bleed  upon  manipulation  by  the 
examining  surgeon.  It  grows  rapidly.  It  often  springs  from  the 
adrenal  and  grows  forward  rather  than  laterally  and  its  presence 


Fig.  3.     FiBRO  cystic  Sarcoma. 

Operated  by  the  author  at  St.  Clair 

Hospital.     Boy  two  years. 


Fig.  4.  Same  case  as  Fig.  3,  two 
years  after  operation,  showing  no 
recurrence. 


usually  excites  ascites.  It  is  most  closely  resembled  by  hydrone- 
phrosis, and  hydroperinephrosis. 

Early  operation  of  sarcoma  of  the  kidney,  as  of  sarcoma  in  any 
situation  that  is  operable,  is  imperatively  indicated. 

Sarcoma  of  the  testicle  occurs  in  childhood.  It  is  next  in 
frequency  to  sarcoma  of  the  kidney.  It  occurs  early,  is  compli- 
cated in  structure,  is  quite  malignant  and  runs  a  rapid  course. 


74 


SURGICAL   DISEASES    OF   CHILDREN 


Primary  sarcoma  of  the  bladder  is  more  frequent  in  infancy 
and  childhood  than  at  any  other  period  of  life,  and  has  so  far 
proved  rapidly  and  inevitably  fatal. 

(For  primary  sarcoma  of  lymphatic  glands  see  section  on  Dis- 
eases of  the  Lymphatic  Glands.) 

Symptoms  and  diagnosis. — A   sarcoma   is  usually   regular  in 

outline,  and  may  be 
globular,  flattened, 
circular,  oblong 
(see  Figs.  2,  3,  4, 
and  5)  or  elliptical, 
accordhig  to  situa- 
tion and  the  sur- 
rounding structures. 
It  is  smooth  and  if 
subcutaneous  not 
attached  to  the 
skin.  If  large,  the 
surface  veins  are 
enlarged.  If  located 
in  soft  parts,  the 
tumor  is  movable. 
Its  consistency  may 
vary  from  solid  to 
fluctuating.  A  soft 
tumor  may  give 
pseudo  -  fluctuation. 
Myelogenous  sar- 
coma may  give  pul- 
sation   and   bruit. 

In  sarcoma  of  in- 
ternal organs,  the 
first  symptoms  are  usually  due  to  pressure  and  vary  according  to 
the  location  of  the  neoplasm.  Sarcoma  usually  grows  more  rapidly 
than  carcinoma.  It  is  more  definitely  distinguished  by  touch  from 
surrounding  structures.  Not  implicating  skin  or  mucous  mem- 
brane, it  grows  larger  before  ulcerating  than  does  carcinoma,  but 
it  infects  the  surrounding  region  and  the  system  more  rapidly. 
As  a  rule  it  does  not  spread  by  way  of  the  lymphatic  system  nor 
implicate  adjacent  glands.  It  spreads  by  the  blood  stream.  It  ex- 
tends locally  along  the  course  of  blood-vessels  or  nerves  or  fascial 
layers.  It  does  not  produce  cachexia  until  it  has  ulcerated  or  gen- 
eral metastasis  has  occurred.  Sarcoma  of  internal  organs  may  be 
accompanied  by  a  rise  of  temperature  resembling  typhoid,  but  less 
regular.     In  all  cases  a  very  searching  and  critical  inquiry  should 


Fig.    S-     Fibro   cystic   sarcoma,    removed    from 
boy   of   2h    years,    shown    in    Fig.   3. 


SURGICAL   PATHOLOGY   OF  THE  DEVELOPING   PERIOD        75 

be  made  as  to  just  where  and  when  the  tumor  first  appeared,  and 
the  rate  of  its  growth.  If  possible,  the  surgeon  should  decide 
whether  the  tumor  started  from  connective  or  epithelial  tissues. 
If  it  takes  its  origin  from  the  mesoblast  and  presents  the  character- 
istics of  malignancy,  it  is  probably  sarcoma.  If  it  springs  from 
epiblastic  or  hypoblastic  tissues,  it  is  probably  carcinoma.  But  the 
most  important  thing  for  the  surgeon  to  decide  clinically  is  that 
the  tumor  is  malignant,  and  his  treatment  must  be  conducted 
accordingly. 

Treatment. — The  treatment  of  sarcoma  is  early  and  thorough 
removal  if  the  situation  of  the  tumor  is  such  that  this  can  pos- 
sibly be  done.  The  growth  of  the  tumor  is  so  rapid  and  its  ex- 
tension into  surrounding  tissues  and  at  large  through  the  system 
is  so  early  that  a  diagnosis  should  be  made  promptly  and  excision 
or  amputation  performed.  Remembering  that  sarcoma  extends  by 
way  of  the  connective  tissues,  the  operator  should  carry  his  inci- 
sion well  beyond  the  margin  of  the  tumor  into  apparently  normal 
tissues,  and  also  remove  the  adjacent  lymphatics,  and  in  subcu- 
taneous sarcoma  the  skin  covering  the  tumor.  In  cases  of  sarcoma 
of  an  extremity,  early  and  thorough  removal  may  succeed  in  eradi- 
cating the  trouble ;  but  it  is  apt  to  be  followed  by  recurrence  neces- 
sitating final  amputation.  Implication  of  large  vascular  or  nervous 
trunks  of  an  extremity  generally  calls  for  amputation  as  a  primary 
operation  at  a  safe  distance  above  the  tumor.  Treatment  of  sar- 
coma by  the  internal  use  of  drugs  is  obsolete.  Local  treatment 
by  electrolysis,  X-rays,  caustics,  and  the  like,  and  partial  removal 
are  worse  than  useless ;  and  excision  or  amputation  after  metastasis 
has  taken  place  are  contra-indicated. 

Treatment  by  use  of  sterile  cultures  of  the  streptococcus  ery- 
sipelatis  and  of  the  micrococcus  prodigiosis  may  be  experimented 
with  in  inoperable  cases,^  and  by  some  has  been  advised  after  all 
excisions  of  sarcoma  upon  external  parts,  in  order  to  prevent 
recurrence. 

Carcinoma. — Cancer  is  less  frequent  in  children  by  far  than 
is  sarcoma.  When  it  does  occur  it  is  most  likely  to  be  an  encepha- 
loma,  with  an  excessive  number  of  cells  in  a  very  sparing  lattice 
stroma.  This  produces  a  soft,  rapidly  growing  tumor  of  great 
malignancy.  The  favorite  sites  of  cancer  in  childhood  are  the 
kidney,  the  eye  or  the  orbit,  and  the  ovary.  Epithelioma  of  the 
lip,  or  growing  from  the  umbilical  scar  or  other  scar  has  been 
known  to  occur,  but  is  a  very  rare  curiosity.  Carcinoma  has  oc- 
curred in  the  mediastinum,  in  teratomata  and  in  certain  congenital 
anomalies.  Melanosis  lenticularis  progressiva  or  xeroderma 
pigmentosa,  may  in  its  later  manifestations  present  a  variety  of  epi- 

^  See  reports  by  Coley  and  Bull. 


yt  SURGICAL  DISEASES    OF   CHILDREN 

thelioma  occasionally  occurring  in  childhood.  Scirrhus  is  so  ex- 
tremely rare  as  to  be  practically  unthought  of  in  examining  a 
child's  tumor. 

Carcinoma  in  children  presents  the  same  characteristics  of 
malignancy  as  like  growth  in  the  adult — the  rapid  growth,  invasion 
of  neighboring  tissues,  implication  of  the  skin  and  lymphatics, 
metastatic  growths,  production  of  systemic  cachexia,  tendency  to 
ulceration  and  hemorrhage,  and  to  recurrence  if  removed. 

Diagnosis. — The  rarity  of  carcinoma  in  children  should  be 
borne  in  mind ;  yet  the  fact  that,  although  rarely,  it  may  occur  in 
childhood,  in  infancy,  or  even  congenitally,  will  prevent  one  from 
dismissing  it  from  the  consideration  of  a  suspected  case.  As  in 
the  adult,  heredity  is  to  be  investigated.  Locality  is  important, 
for  cancer  always  has  its  origin  in  tissue  derived  from  the  epiblast. 
However,  it  might  appear  in  a  teratoma,  dissociated  from  homol- 
ogous tissues.  Carcinoma  in  the  very  young  grows  rapidly,  so 
rapidly  that  it  may  resemble  inflammatory  swelling,  or  a  gum- 
matous enlargement.  But  the  rate  of  its  growth  is  not  as  great  as 
that  of  an  acute  inflammation,  nor  even  as  that  of  gumma.  A 
gumma  would  come  late  in  childhood,  and  would  be  accompanied 
by  other  signs  of  syphilis.  Cancer  would  have  less  pain  and  less 
tenderness  and  less  heat  than  any  inflammatory  swelling  except- 
ing chronic  abscess.  A  cold  abscess  could  be  differentiated  by 
aspiration.  Edema  of  distal  parts  and  dilatation  of  superficial  veins 
might  be  present  with  any  enlargement  which  interfered  with  lym- 
phatic or  venous  circulation.  Redness  upon  the  surface  might 
belong  either  to  cancer  or  to  inflammation.  Hardness  of  the 
tumefaction  is  not  a  sign  likely  to  be  helpful,  as  it  is  seldom  present 
in  carcinoma  in  early  life.  Fluctuation  does  not  settle  the  diagno- 
sis in  favor  of  abscess,  for  a  soft  cancer  may  appear  to  fluctuate. 
Carcinoma  usually  has  definite  margins,  and  infiltrates,  and  in- 
volves surrounding  tissu-es,  and  so  becomes  fixed  in  its  position. 
It  tends  to  softening  and  ulceration.  If  subcutaneous  it  attaches 
itself  to  the  skin. 

A  tumor  with  well-defined  margins,  and  not  very  tender,  with 
adjacent  lymphatic  glands  enlarged  while  the  other  lymph  nodes 
appear  normal  and  there  is  no  ulceration  of  the  skin  or  other  cause 
of  lymphadenitis,  is  a  carcinoma.  Carcinoma  of  the  skin  might  be 
mistaken  for  a  tuberculous  lesion;  but  cutaneous  cancer,  excepting 
xeroderma,  is  almost  unknown  in  children.  Actinomycosis  has  its 
own  characteristic  symptoms.  Chronic  ulcer  is  rare  in  children. 
Syphilis  has  multiple  lesions.  Sarcoma  does  not  implicate  the 
adjacent  lymphatics,  but  extends  by  the  blood  stream.  The  differ- 
entiation from  sarcoma  may  be  impossible ;  and  it  is  not  so  im- 


SURGICAL   PATHOLOGY   OF  THE  DEVELOPING   PERIOD        77 

portant  as  that  the  surgeon  should  recognize  the  malignant  char- 
acter of  the  growth,  and  deal  with  it  accordingly. 

Prognosis. — As  a  rule  the  younger  the  patient  the  more  rapid 
the  growth  and  the  greater  the  malignancy.  As  children  very 
seldom  present  either  of  the  varieties  of  cancer  which  in  the  adult 
are  most  amenable  to  surgical  treatment — the  accessible  epithelioma 
or  the  slow  growing  scirrhus — but  usually  have  the  rapidly  grow- 
ing and  very  malignant  encephaloma,  and  that  often  located  in- 
ternally, the  average  prognosis  is  very  dark  indeed. 

Treatment — Treatment  is  the  same  as  in  the  adult,  early  and 


HHI^V"* 

"^^ 

^^^^^^^^^^^^^^^^^^^^^^^^^^HiH 

■ 

■^^^^^^^■r 

I 

^^^^^^^^^^^^^^    ^ .  jis^ 

^    ^^ 

'\.  .ggfl 

^^^HP^^r 

ji^^^^^n 

^^^^^^^^^Hy^nl^^v 

il 

Fig.  6.     Parasitic  fetus,  attached  to  the  head  of  the  autosite. 
Dr.  I.  N.  Garver. 

complete  removal  if  the  tumor  is  accessible.  If  it  cannot  be  thor- 
oughly removed  with  every  cell  of  the  infected  tissue,  best  not 
operate  at  all.  If  not  operated  upon  it  is  well  to  keep  the  skin 
closed  as  long  as  possible,  or  if  it  opens  to  keep  it  dressed  anti- 
septically  to  prevent  pyogenic  infection. 

Teratoma. — In  infancy  and  childhood  may  be  found  tera- 
toma in  all  its  varieties.  Fetus  in  fetu,  joined  twins,  and  parasitic 
fetus  are  classed  as  ectogenous  teratomata.  Branchial  cysts  and 
dermoids  are  classed  as  endogenous  teratomata.  The  interesting 
controversy  as  to  whether  double  monstrosities  and  parasitic  fetuses 
are  due  to  fusion  of  two  separate  embryos  or  to  a  division  of  the 
imdifferentiated  protoplasmic  cells  of  a  single  embryo,  similar  to 


78  SURGICAL   DISEASES    OF   CHILDREN 

that  which  takes  place  in  lower  animals  and  plants,  I  shall  not 
pause  to  indulge  in.  That  the  dermoids,  with  the  possible  excep- 
tion of  ovarian  dermoids,  originate  from  a  matrix  of  displaced 
embryonal  cells  from  the  epiblast  and  sometimes  also  from  the 
hypoblast  and  mesoblast,  is  an  accepted  theory.  The  teratoma  is 
very  apt  to  show  at  birth  or  to  develop  very  soon  after,  though 
the  dermoid  may  not  appear  until  the  embryonal  matrix  is  stimu- 
lated to  growth  by  the  extraordinary  development  of  the  epiblastic 
structures  which  takes  place  at  puberty.  The  parasitic  fetus  when 
not  included  in  the  autosite  is  very  apt  to  be  attached  to  its  sacrum, 
sternum,  umbilicus  or  head.  Fig.  6  is  from  a  photograph  showing 
the  parasitic  fetus  attached  to  the  head  of  the  autosite. 

The  branchial  cysts  are  of  course  located  in  the  situation  of 
the  branchial  clefts  and  may  be  called  m.ucous,  atheromatous  or 
serous,  according  to  their  contents. 

Dermoids  and  Tridermic  Tumors. — The  generally  accepted 
opinion  is  that  dermoids  are  caused,  not  by  inclusion  of  one  in- 
dividual by  another,  but  by  dissociation  or  dislocation  of  some  of 
the  blastodermic  elements  of  one  individual,  which  took  place 
during  the  developmental  infolding  of  the  various  layers.  These 
misplaced  matrices  developing,  produce  specimens  of  their  various 
structures — for  instance,  skin  or  mucous  membrane,  or  epithelial 
cells  (columnar,  ciliated  or  squamous),  hair  follicles  and  conse- 
quently hair,  sweat  glands  and  their  resultant  secretions,  teeth,  bone 
cartilage  or  nerve  tissue ;  simple  or  more  complex  according  to  the 
nature  of  the  embryonal  elements  that  are  displaced  and  inter- 
mingled. 

This  places  them  in  a  class  by  themselves — the  teratomata, 
distinguished  from  all  other  classes  of  tumors  in  which  only  one 
blastodermic  layer  is  represented.  This  theory  of  their  origin  is 
supposed  to  account  for  the  position  in  which  dermoids  are  most 
often  found,  namely,  where  the  different  germinal  layers  fold  in 
and  coalesce,  near  the  orbit  (Fig.  7),  in  the  neck,  in  the  coccygeal 
region,  in  the  ovary,  in  the  testicle  or  scrotum;  though  they  have 
been  found  in  various  other  regions.  But  some  embryologists 
claim  that  after  impregnation  of  an  ovum  a  single  segmentation 
cell  may  split  off  before  the  establishment  of  the  germ  layers. 
And  they  say  that  it  may  be  presumed  as  probable  that  almost  up 
to  the  formation  of  the  germinal  layers  any  single  segmentation 
cell  even  if  dislocated,  possesses  the  potentiality  of  producing  all 
of  the  layers  if  necessary.  So  that  if  a  cell  of  this  kind  were  caught 
and  infolded  in  the  layers  formed  by  the  other  cells  it  might  pro- 
ceed to  develop  into  a  parasitic  growth  of  complex  or  organized 
structure.  In  that  case  the  difference  in  the  origin  of  included 
fetus  and  of  dermoid  tumor  would  be  that  the  former  came  from 


SURGICAL  PATHOLOGY   OF  THE  DEVELOPING   PERIOD        79 


dissociated  segmentation  cell,  while  the  latter  was  derived  from  a 
misplacement  taking  place  after  the  formation  of  the  layers. 

In  1895  Max  Wilms^  pubHshed  the  results  of  careful  and  ex- 
tensive studies,  in  which  he  claims  that  dermoids  of  the  ovary  are 
not  teratomata,  and  are  therefore  not  present  congenitally ;  but 
that  they  are  formed  directly  from  an  ovule  in  the  ovary,  by  a 
kind  of  parthenogenesis. 
Krcemer's  studies  support 
the  views  of  Wilms ;  and 
Kroemer  shows  that  it  is 
hardly  proper  to  call  the 
process  parthenogenesis  be- 
cause, while  this  is  a  nor- 
mal process  in  lower  plant 
and  animal  life  for  the 
propagation  of  species,  in 
the  case  in  hand  it  is  a 
pathologic  process  in 
which  the  growth  and  de- 
velopment of  organs  are 
atypical  and  without  any 
definite  law.  Dr.  Hans 
Arnsperger  -  agrees  with 
Wilms  and  Kroemer,  and 
they  all  take  the  view  that 
the  embryologic  parts  are 
formed  from  the  ovule  and 
the   cystic   parts    from   the 

follicle.  Wilms  explains  dermoid  cysts  of  the  testicle  in  some- 
what the  same  manner,  by  a  pathologic  growth  of  the  sperm 
cell.  Wilms  proposed  the  name  "  rudimentary  parasites "  or 
"  embryomata  "  for  encysted  tumors  and  "  embryoid  tumors  "  for 
the  solid  variety.  B.  Novy  announces,^  after  a  series  of  mi- 
croscopical studies,  results  virtually  agreeing  with  the  views 
of  Wilms,  who  seems  to  be  the  first  to  have  advanced  proof 
of  the  ovulogenous  theory.  Dr.  Francis  Munch  ■*  gives  an  elab- 
orate critical  review  of  Wilms'  work.  After  referring  to  the 
fact  that  dermoid  cysts  of  the  ovaries  and  testicles  are  dis- 
tinguished from  dermoid  cysts  occurring  elsewhere,  in  that  they 
are    composed    of    three    layers    of    the    blastodern,    Munch    sug- 

1  Deutsche  Archiv.  f.  Klin.  Med.,  Bd.   IV. 

2  Archiv.  fiir  Patholog.  Anat.  and  Physiologic  iind  fiir  Klin.  Med. 
Bd.  156  (Eiinfzehnste  Folge,  Bd.  VI.)  Hft.  I.  Zur  Lehre  von  dem 
sogenannten  Dermoidcysten  des  Ovarium. 

3  Wiener  Klinische  Rundschau,  Aug.  6,   1899. 

4  Semaine  Medicale,  Sept.  6-13,  1899. 


Fig.   7.     Dermoid  cyst,   near  the   orbit. 


8o  SURGICAL  DISEASES    OF   CHILDREN 

gests  the  name  "  tridermic  tumors  "  as  more  appropriate  than 
the  name  proposed  by  Wilms.  He  seems  convinced  that  the  theory 
of  the  parthenogenetic  origin  of  these  tumors,  so  far  as  the  ovary 
is  concerned,  is  well  sustained,  but  that  the  exact  similarity  of  those 
occurring  in  the  testicles  has  not  yet  been  definitely  proven,  al- 
though they  are  probably  also  of  parthenogenetic  origin.  Of 
course  the  beginnings  of  all  dermoids  as  of  all  teratomata  and  of 
all  tridermic  tumors  are  present  at  birth,  and  may  be  noticed  then 
or  not  discovered  until  later.  Dermoids  of  the  testicle,  or  if  we 
accept  the  name  proposed  by  Dr.  Munch,  "  tridermic  tumors  "  of 
the  testicle  are  very  rare.  In  1885  Verneuil  ^  published  an  analysis 
of  nine  cases,  all  he  was  able  to  find  in  the  literature,  to  which  he 
.added  one  case  observed  by  himself  jointly  with  Mr.  Paul  Guer- 
sant.  Dr.  Theodore  Kocher  ^  refers  to  these  ten  cases  of  Verneuil 
and  adds  four  more  cases,  which  were  all  he  was  able  to  find ;  one 
each  from  Tilanus,^  Geinitz,*  in  Altenberg,  Lang,^  in  Insbriick, 
iand  Bitha  and  Bilroth.*'  Mr.  Holmes  (1869)  refers  to  Verneuil's 
cases  and  then  adds  one  from  Dr.  Van  Buren,'  of  New  York. 
Mr.  Curling  states  (1845)  ^^at  "Dr.  Duncan,  of  Edinburgh,  re- 
moved a  congenital  tumor  of  the  testicle  from  a  boy  eight  years 
of  age.  Dr.  Goodsir  examined  the  tumor  and  found  skin,  hairs 
and  portions  of  cartilage  in  it,"  and  he  mentions  Erichsen's  allusion 
to  Mr.  Marshall's  case.^  I  do  not  know  whether  these  cases  were 
among  those  known  to  Verneuil.  In  1886,  D'Arcy  Power  ^  reported 
a  case  and  exhibited  before  the  London  Pathological  Society  a 
specimen  of  a  dermoid  tumor  of  the  testicle  removed  from  a  boy 
of  four  years.  Power  remarks  that  in  the  previous  two  hundred 
years  only  ten  cases  had  been  recorded.  Possibly  he  alludes  to 
those  collected  by  Verneuil.  Manly  ^"  reported  a  case  (in  a  man 
sixty-one  years  old)  before  the  New  York  Academy  of  Medicine, 
February  14,  1899.  C.  C.  Morris  ^^  reports  a  case  of  dermoid  of 
the  testicle  removed  by  him  from  a  boy  of  twelve  years. 

These  are  the  only  cases  that  a  cursory  look  through  the  lit- 
erature brought  to  my  notice.  There  were  probably  others,  but 
dermoids  of  the  testicle  certainly  are  not  common,  for  Mr.  Curling, 
with  all  his  vast  experience,  writes  as  follows :  "  Cysts  containing 

1  Archives  Generales  de     Medecine  5e  serie  t.  v,  et  vl. 

2  Krankheiten     des     Hodens     und     seiner     Hiillen,     des     Nebenhodens 
Samenstrangs  und  der  Samenblasen,  p.  390. 

3  Schmidt's  Yahrbiicher,  100,  171. 
*  Deutsche  Klinic,  1862. 

5  Virchow's  Archiv,  Bd.  53. 
eChirurgie,  Bd3Abth.   II,  T.  Lief. 

7  New  Syd.  Soc.  Bien.  Retrosp.  for  1865-6. 

8  On  Diseases  of  the  Testis,  p.  406,  1852. 

9  London  Lancet,  Oct.  23,  1866. 

10  Jour.  Cutan.  and  Genito-Urinary  Diseases,  V.   17    (1899),  p.  229. 

11  St,  Louis  Med.  Review,  Vol.  XLIV,  No.  19,  p.  326,  Nov.  9,  1901. 


SURGICAL  PATHOLOGY   OF  THE  DEVELOPING  PERIOD        8i 

skin,  hair,  bone,  teeth  and  other  structures  foreign  to  the  part 
have,  in  some  rare  instances,  been  found  in  the  scrotum  in  connec- 
tion with  the  testicle.  No  case  of  the  kind  has  fallen  under  my 
notice." 

Senn  says  (1900) :  "There  is  no  doubt  that  most  of  the  cases 
of  dermoid  tumors  of  the  testicle  that  have  been  reported  were  not 
within  the  testicle,  but  were  on  it — that  is,  were  dermoids  of  the 
scrotum.      That    dermoids    in 
this   locality   are   not   common 
is  evident   from  the   fact   that 
Kocher  ^    found   only    fourteen 
cases  recorded  in  literature." 

In  1902  I  reported  -  a 
case  of  dermoid  of  the  testicle. 
Wm.  T.,  aged  two  and  one- 
half  years,  brought  to  me  on 
account  of  a  growth  of  the 
size  of  an  English  walnut  in 
the  situation  of  the  left  testi- 
cle. His  mother  was  positive 
it  had  not  been  there  at  birth 
nor  until  he  was  a  year  old ; 
but  since  appearing  it  had 
grown  slowly  and  steadily, 
notwithstanding  that  both  in- 
ternal medicines  and  local  ap- 
plications from  several  physi- 
cians   had    been    used.      The 

tumor  was  firm,  the  lower  end  being  of  a  bony  hardness,  and  the 
upper  portion,  though  fluctuating  slightly,  very  tense.  No  pain, 
redness,  tenderness,  nor  apparent  heat.  The  scrotum  was  movable 
over  the  tumor.  The  veins  showed  rather  large  and  blue  upon  the 
surface.  There  was  no  enlargement  of  adjacent  lymphatics.  Upon 
these  data  I  based  a  diagnosis  of  dermoid  cyst  and  removed  it.  The 
tumor  corresponded  anatomically  to  the  testicle  and  did  not  involve 
any  structure  but  the  testicle.  Recovery,  uneventful.  When  seen 
seven  and  a  half  years  later,  patient  was  a  large  healthy  boy.  Fig. 
8  is  from  a  photograph  of  the  tumor,  which  contained  bone,  fine 
hairs  and  several  cavities  filled  with  the  sebaceous-appearing  ma- 
terial found  in  dermoids. 

Ovarian  dermoids  are  not  nearly  so  rare  as  those  of  the  tes- 
ticle. The  following  case  presented  additional  symptoms  of  ob- 
struction  of   the   bowels   and   illustrates   points    in   the   diagnosis. 


^H^^^^^^'PpI^^I 

^^^^^^1  •»              <«.  '  V  HB^I 

^^^^^^^^B                                                  '4.  ^^^I^^^^H 

Fig.  8.  Dermoid  of  testicle,  re- 
moved from  Wm.  T.,  aged  2J 
years. 


1  Pathology  and  Surgical  Treatment  of  Tumors,  1900,  p.  655. 

2  Jour.  American  Med.  Ass'n,  Feb.  14th,  1903. 


82 


SURGICAL   DISEASES    OF   CHILDREN 


Elsie  IM.,  aged  seven  years  and  ten  months,  American  born,  third 
child  of  German  parents  who  had  six  children.  Others  all  healthy 
and  no  history  of  tumors  or  deformities  in  the  family.  Elsie  was 
small  for  her  age,  weighing  41^  pounds.  (Average  weight  for 
girls  at  seven  years  is  48  pounds,  at  eight,  52.9.)  She  was  pale, 
delicate,  fair,  bright  and  lively,  had  had  only  whooping-cough  and 
measles.    Two  and  a  half  months  previously  she  had  been  very  sick 

with  what  had  been  called 
"  inflammation  of  the 
bowels,"  with  severe  pain 
in  the  abdomen  and  in- 
testinal obstruction.  Seven 
weeks  later  she  had  suf- 
fered a  second,  similar  at- 
tack, which  was  severe 
during  four  and  a  half 
days,  when  it  subsided 
rather  promptly.  On  my 
first  examination,  June  11, 
1900,  a  tumor  was  easily 
palpable  in  the  hypogas- 
tric region  and  seemed  to 
be  of  the  shape  of  a  dis- 
tended bladder.  It  ex- 
tended nearly  to  the  um- 
bilicus, was  dull  on  per- 
cussion, and  firm,  no  fluc- 
tuation being  made  out. 
It  was  only  slightly  mov- 
able in  its  position.  The 
parents  declined  operation. 
June  18.  On  the  previous 
day  the  child  had  had  an 
attack  of  pain  lasting 
about  an  hour.  Urine  scanty.  Tumor  much  more  movable. 
It  could  be  moved  upward  till  its  upper  margin  was  nearly 
an  inch  above  the  umbilicus  and  a  space  separated  it  from  the 
OS  pubis,  and  was  movable  laterally.  June  25.  The  tumor  could 
be  moved  freely  upward  and  to  the  left  lumbar  region — not  so 
far  on  the  right  side.  Tried  to  get  a  skiagraph  in  hope  of  show- 
ing teeth  or  bone,  but  the  result  was  unsatisfactory.  Parents  still 
refused  operation,  although  the  possibility  of  the  supervention  of 
malignancy,  danger  from  purulent  inflammation  and  resultant 
peritonitis  which  might  be  fatal  or  cause  adhesions  and  render 
removal   of  the  tumor  more   difficult  later, — danger   from   twisted 


Fig.  9.  Dermoid  of  ovary,  removed 
from  Elsie  M.,  aged  7.  The  cyst 
contained  fluid.  Its  walls  contained 
irregularly  shaped  pieces  of  cartilage 
part  of  which  was  ossified,  masses  of 
atheromatous  material  and  fine  hairs. 


SURGICAL  PATHOLOGY   OF  THE  DEVELOPING   PERIOD        83 

pedicle,  from  obstruction  of  the  bowels,  or  from  pressure  on  the 
bladder,  were  explaind  to  them.  On  July  22^  patient  had  an  alarm- 
ing attack  of  "  inflammation  of  the  bowels/'  Extreme  abdominal 
pain,  worse  in  paroxysms,  a  quick  pulse,  and  intestinal  obstruction. 
Enemata  and  local  heat  had  been  used  without  relief.  I  thought 
it  probable  that  a  loop  of  intestine  was  pressed  between  the  tumor 
or  its  pedicle  and  the  spine.  On  placing  the  patient's  body  almost 
vertically,  head  downward  in  an  exaggerated  Trendelenburg  posi- 
tion, massaging  the  abdomen  and  using  copious  enemata,  free 
escape  of  gases  and  feces  occurred,  the  pain  ceased,  and  the  attack 
was  ended.  This  alarming  attack  decided  the  parents  for  opera- 
tion. September  29,  at  Cleveland  General  Hospital,  I  removed  the 
tumor  through  a  small  median  incision.  It  proved  to  be  a  dermoid 
cyst  of  the  left  ovary,  of  the  size  of  an  orange,  and  consisting  of  a 
cyst  containing  fluid,  and  a  solid  portion  containing  irregular- 
shaped  pieces  of  cartilage,  part  of  which  is  ossified,  masses  of 
atheromatous  material  and  fine  hairs.  Recovery,  uneventful.  Fig. 
9  is  from  a  photograph  of  the  tumor. 

Angioma. — Representatives  of  the  angiomata  are  quite  com- 
mon in  early  life.  Capillary  angioma  or  nevus  is  the  form  most 
frequently  met.  It  is  always  congenital,  and  even  though  small  at 
birth  it  may  soon  show  noticeable  growth.  The  favorite  site  of 
nevus  is  the  face  and  orbit,  but  it  may  come  anywhere  upon  the 
skin  or  upon  the  mucous  membrane  or  where  the  two  join. 

A  cavernous  angioma  usually  requires  more  time  for  its 
growth  and  may  attain  quite  troublesome  size  in  some  situations 
in  later  infancy,  childhood  or  youth.  It  may  be  situated  not  merely 
in  the  skin  but  in  deeper  connective  tissues,  even  in  bone,  and  in 
such  organs  as  kidney,  liver  or  spleen. 

The  plexiform  angioma,  which  formerly  was  wont  to  be  called 
"  cirsoid  aneurism "  or  "  aneurism  by  anastomosis,"  is  most  apt 
to  appear  about  the  brows  or  temples,  or  about  the  arms,  the  legs, 
or  the  fingers,  but  may  attack  connective  tissues  anywhere. 

Superficial  angioma  or  nevus  may  in  time  become  cavernous, 
or  plexiform,  and  extend  not  only  wider  but  deeper.  (See  Fig  10.) 
An  angioma  may  be  no  larger  than  a  pinhead,  or  it  may  cover  a 
whole  extremity  or  displace  important  organs.  Senn  quotes  a  case 
reported  by  W.  Koch  of  an  angioma  which  at  the  birth  of  the 
child  was  of  the  size  of  a  walnut,  located  above  the  right  clavicle. 
It  grew  slowly  until  the  child  died  at  the  age  of  eighteen  months. 
The  tumor  then  measured  fifteen  inches  in  a  horizontal  and  seven 
in  a  vertical  direction.  The  tumor  was  made  up  of  three  compart- 
ments, only  one  of  which  was  external,  one  occupied  the  deep 
region  of  the  neck,  and  the  third  occupied  the  mediastinum  and 
the  right  pleural  cavity,  where  it  had  displaced  the  lung. 


84 


SURGICAL   DISEASES    OF   CHILDREN 


Angiomata  of  the  tongue,  palate  or  rectum  are  not  uncommon, 
and  have  been  reported  in  various  muscles  and  in  the  mammary 
gland.  They  may  also  occur  within  the  cranium  and  in  the  larynx. 
An  angioma  is  composed  of  a  network  or  plexus  of  blood-ves- 
sels or  cavities  which  had  no  previous  existence,  but  grew  from 
an  arrested  matrix  of  angioblasts.  They  have  a  structure  of  con- 
nective tissue  and  muscle  and  a  lining  of  endothelium  similar  to 
normal  vessels ;  but  they  do  not,  like  normal  vessels,  cease  to  grow 
when  they  have  attained  the  proper  size  and  number.     They  go  on 

increasing  and  multiplying,  com- 
municating with  the  previously 
formed  vessels  of  the  tumor  tis- 
sue and  with  the  normal  vessels. 
They  may  be  stationary  or  grow 
slowly  or  rapidly,  or  may  take  on 
inflammation,  with  all  the  dan- 
gers of  sepsis  or  septic  thrombo- 
phlebitis, or  they  may  through 
inflammation  undergo  spontane- 
ous cure.  They  may  become 
transformed  into  very  malignant 
sarcoma,  may  undergo  hyaline  or 
colloid  degeneration  or  calcifica- 
tion. (8) 

Diagnosis. — An  angioma  lo- 
cated upon  the  surface,  or  be- 
neath the  surface,  unless  its 
integuments  are  very  thick, 
shows  the  color  of  the  blood 
which  it  contains,  whether  capillary,  venous  or  arterial.  Any 
variety  of  angioma  excepting  the  capillary  is  increased  in  size 
and  tension  by  laughing,  crying,  straining,  and  the  like,  or  by 
placing  the  patient  with  the  tumor  dependent.  The  capillary  an- 
gioma heightens  its  color  from  the  same  causes.  An  angioma  can 
be  decreased  in  size  or  temporarily  obliterated  by  pressure  with 
the  fingers,  but  returns  immediately  when  the  pressure  is  relieved. 
A  plexiform  angioma  upon  the  surface  usually  pulsates.  In  the 
cavernous,  sometimes  tortuous  vessels  can  be  felt.  An  abscess  or 
inflammatory  swelling  or  some  other  variety  of  tumor  may,  if  placed 
over  a  large  artery,  appear  to  pulsate  like  a  plexiform  angioma  or 
an  aneurism.  But  aneurism  is  rare  in  the  child ;  and  the  angioma 
may  be  differentiated  from  the  inflammatory  swelling,  abscess  or 
lymphangioma,  by  puncture  with  an  aspirating  needle.  An  angi- 
oma located  internally  could  not  be  dift'erentiated  from  aneurism 
in  an  adult.     But  a  compressible  pulsating  tumor,  located  internally 


Fig.  10.  Cavernous  nevus.  Babe 
6  months  old.  Growth  not 
noticed  at  birth,  but  grew  rap- 
idly.    Removed  by  excision. 


SURGICAL   PATHOLOGY   OF  THE  DEVELOPING   PERIOD        85 

in  a  child,  not  in  the  course  of  a  great  vessel,  may  be  considered  an 
angioma. 

Prognosis. — Angioma  is  a  benign  growth ;  but  it  may  become 
plexiform ;  and  it  may,  as  has  been  said,  become  the  seat  of  sar- 
coma. Surface  angioma  may  undergo  spontaneous  cure  from  in- 
flammation resulting  from  the  chafing  of  clothing,  etc.  But  inflam- 
mation has  all  the  dangers  of  septicemia,  septic  thrombosis,  phlebitis 
or  pyemia.  One  sometimes  sees  a  large  surface  angioma  under- 
going an  obliterative  ulceration  or  already  cicatrized  in  its  central 
part,  while  still  remaining  or  even  extending  at  its  periphery. 
(See  Fig.  11.) 


Fig.  II.     Nevus  of  hand,  ulcerating. 

Either  ulceration  or  an  accidental  wound  may  occasion  serious 
hemorrhage.  When  located  near  the  eye,  mouth,  palate,  tongue, 
anus,  angioma  may  produce  distortion  of  parts  and  interference  with 
function.     (See  Fig.  12.) 

Treatment. — The  possibility  of  spontaneous  cure  of  angioma 
is  not  to  be  waited  for.  Its  coming  is  unusual,  and  when  it  does 
occur  it  is  tedious  and  uncomfortable  in  process,  and  often  results 
in  greater  scarring  and  deformity  than  would  proper  interference. 
The  mxinute  stellate  nevus  should  be  destroyed  by  the  point  of  the 
electric  needle.  The  common  mother's-mark  or  port-wine  stain 
can  be  removed  by  electrolysis,  ethyl  chloride  (9),  or  ethylate  of 
soda,  acetic  acid,  ten  per  cent,  of  mercuric  bichloride  in  collodion, 
the  Paquelin  cautery,  or  any  mild  and  manageable  escharotic.  The 
plan  is  to  produce  a  shallow  eschar,  and  then  under  antiseptic 
dressing,  promote  healing.  If  the  extent  of  the  morbid  process 
is  not  too  wide  the  white  scar  which  results  will  be  less  of  a  disfigure- 
ment than  the  deep  color  of  the  growth.  But  if  the  growth  be  more 
than  an  inch  and  a  half  or  thereabout  in  diameter  there  is  small 


86 


SURGICAL   DISEASES    OF    CHILDREN 


choice  between  the  stain  and  the  scar.  Of  course  the  acids  and 
caustics  should  not  be  used  in  proximity  to  the  eye,  and  wherever 
they  are  used  surrounding  parts  should  be  protected.  Electrolysis 
is  quite  controllable  in  such  situations,  but  is  tedious  for  wide 
areas.  Nevus  or  cavernous  angioma  upon  the  face  or  conspicuous 
parts  is  nicely  removed  with  the  galvanic  needle.  Anesthesia  is 
required.  After  antiseptic  cleansing  of  the  skin,  the  needle  con- 
nected with  the  positive  pole  is  introduced  into  the  growth  while 

the  negative  pole  con- 
nected with  a  wet  sponge 
electrode  is  applied  to 
any  convenient  surface 
of  the  body.  Sufficient 
current  is  used  to  blanch 
the  tissues.  The  object 
is  to  alter  the  blood-ves- 
sels and  coagulate  the 
blood.  From  ten  to 
thirty  milliamperes  may 
be  required  to  cause 
electrolysis.  If  complete 
disorganization  is  de- 
sired thirty  to  fifty  milli- 
amperes will  be  used.  If 
not  supplied  with  a  gal- 
vanometer, the  current 
can  be  tested  by  plac- 
ing both  poles  in  water. 
Enough  cells  should  be 
thrown  into  the  cir- 
cuit to  cause  small 
gas  bubbles  to  form  and  rise  from  the  point  of  the  needle. 
Special  needles  of  platinum  are  best  for  this  work.  They  are  insu- 
lated excepting  at  their  points,  and  are  introduced  beyond  the  insu- 
lation. If  used  where  slight  scarring  is  not  of  great  consequence, 
ordinary  platinum  or  even  steel  needles  will  give  very  good  results. 
The  needle  after  being  introduced  at  one  point  may  be  partly  with- 
drawn, and  cautiously  thrust  in  other  directions  within  the  tumor. 
Two  to  five  minutes  of  the  current  usually  suffices  for  one  point. 
After  turning  off  the  current  to  avoid  burning  the  skin,  the  needle 
should  be  withdrawn  cautiously,  lest  hemorrhage  follow  it.  A 
sterile  dressing  is  applied.  It  is  surprising  how  little  scar  will  be 
left  after  extensive  use  of  galvanism.  Pressure,  as  of  a  bandage, 
helps  to  reduce  or  even  sometimes  remove  extensive  nevi  upon 
^jctremities. 


Fig.    12.     Nevus  of  the  lip. 


SURGICAL   PATHOLOGY   OF   THE  DEVELOPING   PERIOD        87 

The  galvanic  needle  can  be  used  conveniently  within  the 
mouth  or  rectum.  Igni-puncture  with  the  needle  point  of  the 
Paquelin  cautery  can  be  used  instead  of  electrolysis.  But  it  can- 
not be  so  accurately  done  and  leaves  more  scar.  It  is  preferable 
in  extensive  growths  and  those  situated  where  excision  is  impos- 
sible, as  one  can  work  so  much  more  rapidly  than  with  the  elec- 
trolysis. In  igni-puncture  the  needle  should  be  heated  cherry-red. 
White  heat  is  apt  to  be  followed  by  hemorrhage.  In  using  the 
Paquelin  button  or  point  upon  the  skin  surface  to  destroy  capil- 
lary nevi,  bright  red  or  white  heat  can  be  used  with  the  quickest 
possible  touch.  The  best  treatment  for  angioma  on  the  body  and 
limbs,  and  also  sometimes  on  the  face,  is  excision.  Care  should  be 
taken  to  keep  the  incision  outside  the  boundaries  of  the  tumor. 
Cutting  into  the  tumor  will  cause  troublesome  or  even  serious 
hemorrhage,  but  a  short  distance  outside  of  the  tumor  the  tissues 
are  not  abnormally  vascular.  An  excellent  method  of  destroying 
nevi  by  altering  their  structure  is  by  injection  into  them  of  very 
hot  water.  Boiling  water  is  drawn  into  an  aspirating  syringe,  and 
the  skin  about  the  nevus  having  been  previously  surgically  cleansed 
the  needle  is  thrust  in  through  sound  skin  at  its  base  and  a  portion 
of  the  water  injected  here  and  there.  Aseptic  inflammatory  reac- 
tion takes  place,  obliterating  the  growth.  It  is  reported  that  radium 
can  be  used  in  the  treatment  of  nevi.  (Wickham  and  D'Egrais, 
Med.  Bull.,  Jan.,  1908.)  Plates  varnished  with  a  substance  with 
which  radium  is  incorporated  are  applied,  the  dose  being  regulated 
according  to  the  extent  and  depth  of  the  nevus.  It  is  claimed  the 
resulting  scars  are  soft,  smooth  and  without  color ;  that  the  treat- 
ment is  painless,  and  can  be  applied  to  a  child  during  sleep. 

Lymphangioma. — Lymphangioma  is  similar  to  angioma,  but 
contains  lymph  instead  of  blood.  It  is  not  composed  of  lymphatic 
glands,  nor  yet  of  enlarged  lymphatic  spaces,  but  of  new  lymphatic 
vessels  produced  from  a  matrix  of  angioblasts  lined  with  endothe- 
lial cells.  Yet  it  may  be  impossible  to  distinguish  in  a  given  tumor 
whether  it  is  composed  of  previously  existing  lymph  vessels  or 
is  formed  from  new  vessels,  or  of  both.  It  has  no  function  and 
may  even  be  located  where  there  are  normally  no  lymphatics. 
There  is  considerable  confusion  in  the  use  of  the  names  for  this 
condition,  as  well  as  many  mistakes  in  diagnosis.  One  finds  such 
tumors  described  not  only  as  lymphangioma,  but  as  hygroma,  cystic 
hygroma,  congenital  cystic  hygroma,  hydrocele  of  the  neck,  and 
confused  with  lymphoma,  lymphadenoma,  and  branchial  cysts.  By 
some,  cystic  hygroma  is  used  to  designate  a  cavernous  hygroma  that 
has  undergone  cystic  degeneration. 

The  foregoing  definition  sufficiently  indicates  its  nature.  An 
enlarged  and  tortuous  lymphatic  vessel  is  called  a  lymph  varix. 


88  SURGICAL  DISEASES    OF   CHILDREN 

Lymphangioma  may  be  capillary,  cavernous,  or  cystic.  It  has  no 
limiting  capsule.  It  is  usually,  though  not  invariably,  congenital. 
It  lis  innocent  in  its  nature,  but  may  do  harm  by  pressure  upon  or 
displacement  of  important  vessels  or  organs  or  occlusion  of  pas- 
sages. It  may  grow  rapidly  or  remain  stationary ;  may  be  combined 
with  angioma;  may  undergo  inflammation,  with  all  the  dangers 
of  extensive  infection.  It  is  subject  to  nearly  all  the  degenerative 
changes  of  other  tumors.     It  may  occur  in  almost  any  part  of  the 

body,  although  favorite  sites 
are  the  neck,  clavicular  region, 
shoulder  or  axilla,  the  tongue 
or  beneath  the  tongue,  the  lips 
or  cheeks,  or,  more  rarely,  up- 
on the  abdomen.  (See  Fig. 
13.)  It  has  been  found  in  the 
groin  or  upon  the  buttocks  or 
extremities.  When  occurring 
in  the  tongue  it  produces  mac- 
roglossia. 

Diagnosis.  —  Lymphangioma 
is  usually  congenital.  The  skin 
overlying  the  tumor  is  normal 
or  paler  than  normal,  unless 
there  is  inflammation.  Lym- 
phangioma is  not  compressible 
like  angioma,  unless  containing 
also  blood-vessels — making  it  a 
hemo-lymphangioma.  If  in  doubt,  the  aspirating  needle  may  be 
used.  If  clear  lymph  is  drawn,  the  tumor  is  a  lymphangioma;  if 
a  mixture  of  lymph  and  blood,  it  is  hemo-lymphangioma.  Very 
rapid  growth  raises  the  suspicion  of  implication  with  sarcoma;  but 
that  point  could  only  be  settled  by  the  microscope.  If  a  lym- 
phangioma bursts  or  is  lanced  a  lymphorrhea  may  result  and  prove 
a  serious  drain. 

Prognosis. — Gradual  growth  is  common;  rapid  growth  less 
common.  Unless  containing  sarcomatous  elements  it  is  only  dan- 
gerous to  the  degree  that  it  presses  upon  important  organs  or 
interferes  with  function. 

Treatment. — If  favorably  situated,  excision  is  the  treatment. 
In  planning  excision  it  is  well  to  understand  that  the  growth  may 
extend  to  unknown  depths.  For  example,  apparently  superficial 
upon  the  supraclavicular  region,  it  may  extend  beneath  and  around 
the  great  vessels  and  nerves  in  the  triangles  of  the  neck,  and,  hav- 
ing no  capsule,  very  nice  dissection  will  be  necessary:  Mr.  Owen 
has  remarked  upon  the  ragged  and  insignificant  appearance  of  the 


Fig.  13.  Lymphangioma  or  Hygroma. 


SURGICAL   PATHOLOGY   OF  THE  DEVELOPING   PERIOD        89 

collapsed  tumor  after  it  is  removed.  If  the  hygroma  is  cystic  he 
recommends  tapping  the  cysts,  or  repeated  tappings,  and  waiting 
for  spontaneous  changes.  Tapping  may  be  useful  in  single  or  thin- 
walled  cysts,  but  it  is  useless  in  the  multilocular  forms.  (Power.) 
Setons  were  formerly  used,  but  are  unsurgical  and  unsafe.  If  so 
located  that  complete  excision  is  impossible,  partial  excision  is  per- 
missible;  or  injections  may  be  used  to  produce  fibrosis  and  shrink- 
ing. Iodine  has  been  recommended;  also  carbolic  acid.  One  case 
in  which  I  tried  iodine  did  not  succeed  very  well.  A  10  per  cent, 
solution  of  chloride  of  zinc  or  a  weak  solution  of  bichloride  of  mer- 
cury are  better.  Large  lymphangioma,  involving  a  whole  limb, 
can  be  treated  by  a  combination  of  injection  and  pressure  by  ban- 
daging. 

Cystoma. — As  representative  of  the  cystoma  in  children  there 
is  a  group  of  cysts  in  connection  with  the  jaws.  One  form  is 
multilocular,  due  to  an  epithelial  infolding  upon  the  alveolar  mar- 
gin, which  produces  the  cyst.  Dentary  cysts  comprise  another  form. 
They  are  either  follicular,  arising  from  the  tooth  follicles,  or  they 
are  dentigerous,  which  originate  with  misplaced  teeth,  either  of  the 
temporary,  more  often  of  the  permanent,  set,  and  contain,  besides 
the  erratic  tooth,  a  fluid  which  may  be  clear,  watery,  colored,  glairy, 
possibly  purulent.  An  enlargement  of  the  jaw,  sometimes  with  dis- 
tinct egg-shell  crackling,  situated  where  a  tooth  has  failed  to  appear, 
raises  strong  suspicions  of  the  nature  of  the  trouble.  When  an 
opening  is  made  and  the  fluid  and  tooth  are  removed  the  case  is 
settled. 

Congenital  Tumors  of  the  Spinal  and  Sacral  Region. — 
Turning  now  from  our  histological  nomenclature,  let  us  consider 
a  group  of  tumors  which  are  always  congenital  and  always  located 
in  the  region  of  the  spine,  and  most  frequently  near  the  sacrum. 
They  are  not  cases  of  spina  bifida ;  and  did  not  all  arise  in  the  same 
manner  as  spina  bifida,  although  that  condition  in  several  kinds  is 
often  classed  with  this  group. 

They  constitute  a  class  sometimes  loosely  called  "  false  spina 
bifida."  It  has  been  stated,  in  speaking  of  teratoma,  fibroma,  lipoma, 
sarcoma,  and  angioma,  that  any  of  them  may  occur  in  the  region 
of  the  sacrum  and  with  some  of  them  this  is  a  favorite  site.  They 
may  occur  as  simple  tumors,  but  more  frequently  as  growths  com- 
pounded of  more  than  one  kind  of  tissue,  and  some  of  them,  espe- 
cially naevoid  tissue,  may  be  combined  with  spina  bifida.  A  form 
of  cystic  hygroma,  lymphangioma,  may  occur  in  this  region  as  either 
simple  or  multiple  cysts  of  obscure  origin. 

Any  of  the  tumors  in  this  region  may  be  suspected  of  having 
attachments  to  the  spinal  cord  or  its  membranes  or  within  the 
spinal  canal,  but  are  distinguished  from  true  spina  bifida  in  that 


90 


SURGICAL   DISEASES    OF   CHILDREN 


they  have  no  cavity  connecting  with  the  cavity  of  the  spinal  canal, 
nor  of  an  expansion  of  the  central  cavity  of  the  cord,  and  contain 
no  portion  of  the  cord. 

Fig-.   14  is  from  a  photograph  of  a  congenital  tumor  of  the 
spine,  taken  when  the  boy  was  fifteen  months  old.     The  tumor  is 

in  the  median  line,  in  the 
region  of  the  second  and 
third  cervical  vertebrae,  of 
the  size  of  a  small  hen's 
egg,  and  has  a  pedicle  two 
and  a  half  inches  in  cir- 
cumference. It  is  said  not 
to  have  varied  much  in 
size,  excepting  to  keep 
pace  with  the  growth  of 
the  child.  The  surface  of 
the  tumor  is  bluish  over 
the  fundus,  has  a  dimple 
or  pucker  which  shows  in 
the  photograph,  and  is 
supplied  with  hair  like  the 
scalp  in  a  circle  toward 
the  base.  It  feels  quite 
firm  and  fibrous,  both  in 
the  body  and  in  the  pedi- 
cle. One  cannot  be  cer- 
tain whether  the  pedicle 
distends  when  the  child 
cries,  or  whether  that  ap- 
pearance is  due  to  the 
movements  of  the  mus- 
cles near  its  attachment, 
as  at  times  it  seems  to 
vary  with  position.  This 
raises  the  question 
whether  position  may  not  occlude  or  open  a  passage  from 
spinal  or  meningeal  cavity  to  tumor.  Although  the  tumor  appears 
in  the  region  of  the  second  or  third  cervical  vertebrae,  its  real  origin 
may  be  from  the  foramen  magnum  or  through  the  atlas.  (See 
Section  on  Meningocele.)  It  is  impossible  to  tell  whether  there  is 
a  connection  with  the  cranial  or  spinal  meninges,  or  to  be  sure 
whether  there  is  a  cavity  within  the  tumor.  Its  hairy  scalp-like 
covering  gives  it  the  appearance  of  a  cranial  rather  than  a  spinal 
meningocele ;  but  spina  bifida  and  other  tumors,  even  low  upon  the 
spine  and  elsewhere,  may  be  hairy.    Operation  advised,  but  declined. 


Fig.  14.  Congenital  tumor,  described 
in  the  Section  on  Congenital  Tumors 
of  the  Spinal  and  Sacral  regions. 
Boy   15   months   old. 


SURGICAL   PATHOLOGY   OF   THE  DEVELOPING   PERIOD        91 

The  coccygeal  tumors,  so  called,  spring  from  the  anterior  sur- 
face of  the  sacrum  or  coccyx,  and,  while  they  may  develop  inside 
the  body,  occupying  the  space  between  the  sacrum  and  rectum, 
they  are  likely  to  appear  externally  in  the  perineal  region.  They 
may  be  as  small  as  a  nut  or  a  lemon,  or  attain  a  size  much  larger 
than  the  child's  head.  Senn  quotes  Sutton's  explanation  of  the 
embryological  origin  of  these  tumors,  as  follows :  "  In  the  early 
embryo  the  central  canal  of  the  spinal  cord  and  the  alimentary 
canal  are  continuous  around  the  caudal  extremity  of  the  notochord. 
This  passage,  which  brings  the  developing  cord  and  gut  into  such 
intimate  relations,  is  known  as  the  '  neurenteric  canal.'  When  the 
proctodeum  invaginates  to  form  part  of  the  cloacal  chamber  it 
meets  the  gut  at  a  point  some  distance  anterior  to  the  spot  where 
the  neurenteric  canal  opens  into  it ;  hence  there  is  for  a  time  a  seg- 
ment of  intestine  extending  behind  the  anus  and  termed,  in  conse- 
quence, the  '  post-anal  gut.'  Afterward  this  post-anal  section  of 
the  embryonic  intestine  disappears,  leaving  merely  a  trace  of  its 
existence  in  the  small  structure  at  the  tip  of  the  coccyx,  known  as 
the  '  coccygeal  body.'  "  The  tumor  called  "  congenital  cystic  sar- 
coma," and  those  considered  by  Braun,  Albert,  and  others  as  aris- 
ing in  Luschka's  coccygeal  gland,  are  thought  by  many  modern 
pathologists  to  arise  from  the  remains  of  the  post-anal  gut  (Senn). 
Some  of  them  are  thyroid  dermoids  containing  cysts  lined  with 
columnar  epithelium  and  filled  with  mucus.  Some  of  these  coccygeal 
tumors  consist  of  a  fibrous  layer,  covered  by  integument  and  con- 
taining a  granular  sarcomatous  mass.  Sometimes  they  resemble 
dermoids  in  containing  cartilage,  bone,  or  sebaceous  matter,  hair  or 
teeth.     Some  have  also  sarcomatous  tissue. 

A  different  variety  of  abnormal  growth  in  this  region  is  an 
increase  in  the  size  or  number  of  the  bones  of  the  coccyx,  forming 
a  tail.  Or  the  coccyx  may  have  as  an  appendage  a  lipomatous 
tumor. 

RETENTION  CYSTS 

We  must  pay  some  attention  to  a  form  of  tumefaction  which 
differs  from  the  true  tumors  and  also  from  the  inflammatory  swell- 
ings, namely,  the  retention  cysts. 

A  retention  cyst  is  a  swelling  caused  by  obstruction  of  the  out- 
let of  a  gland  or  the  retention  of  its  secretion  or  excretion  in  a  pre- 
existing space.  The  mechanical  obstruction  which  causes  the 
retention  cyst,  Senn  classifies  as  follows:  (i)  Inflammation,  (2) 
cicatricial  stenosis,  (3)  tumors,  (4)  flexion  of  a  duct,  (5)  valvular 
closure,  (6)  altered  secretion,  (7)  impaction  in  the  duct  of  a  for- 
eign body,  a  concretion,  or  a  parasite — the  first,  those  due  to 
inflammation   and  its   consequences,   being   far  the   most   frequent. 

As  would  be  expected  on  a  moment's  reflection,  certain  varieties 


92 


SURGICAL   DISEASES    OF    CHILDREN 


of  these  retention  cysts  are  practically  unknown  in  childhood — ■ 
for  instance,  hydrometra,  hydro-kolpos,  hydro-salpynx,  galactocele, 
cysts  of  spermatic  tubes,  and  of  Bartholin's  gland,  and  hydrops  of 
the  gall-bladder.  Cyst  of  the  pancreas  is  rare  at  any  age,  and  I  at 
least  have  never  met  cyst  of  the  thyroid  in  a  child,  although  goiter 
is  not  uncommon.  Retention  cysts  of  the  sebaceous  glands  are  not 
found   in   children ;   and  the   smallest   of   the   sebaceous   cysts,   the 

comedos  and  the  lesions  of 
acne,  which  are  inflamed 
comedos,  are  reserved  for 
the  annoyance  of  adoles- 
cence. 

Retention  cysts  of  the 
ducts  of  the  sub-lingual  and 
sub-maxillary  glands  occur 
and  are  described  under  the 
name  ranula.  One  has 
seen  them  of  the  size  of 
a  hickory-nut,  filled  with 
glairy  fluid.  If  opened  the 
incision  rapidly  reunites.  A 
seton,  made  of  a  small  loop 
of  silver  wire,  establishes 
a  permanent  opening  for 
drainage,  and  cures  the 
cyst. 

Occasionally      an       extra 
or  disconnected  lobe  of  the 
parotid     gland     develops    a 
cyst.     (See  Fig.  15.) 

Congenital  cystic  kidney  is  one  of  the  not  infrequent  affections 
of  infancy.  A  nephritis  occurring  in  the  fetus  may  cause  a  plug- 
ging of  uriniferous  tubules  by  hyperplasia  of  connective  tissue,  by 
debris  or  clots,  in  the  same  manner  as  occurs  in  the  adult.  Or 
disease  of  the  fetal  kidney-pelvis,  or  a  developmental  failure  of  union 
between  the  renal  and  collecting  tubules,  may  be  the  obstructing 
cause.  The  result  is  the  same  as  sometimes  occurs  in  interstitial 
nephritis  of  the  adult — the  obstructed  tubules  dilate  and  form  cvsts. 
One  or  both  kidneys  of  the  infant  at  birth  may  be  small,  composed 
of  connective  tissue  and  numerous  small  cysts;  or  the  distention  of 
the  cysts  may,  by  pressure,  obliterate  the  renal  tissue  and  expand  to 
such  a  size  that  the  abdominal  walls  can  hardly  contain  them.  The 
fluid  in  the  cysts  may  contain  urinary  salts,  or  these  may  have  dis- 
appeared, leaving  only  serum.  Cystic  kidney  causes  the  death  of 
many  fetuses.     Children  born  alive  with  double  cystic  kidney  gen- 


FiG.  15.     Cyst  of  the  socia  parotidis. 


SURGICAL   PATHOLOGY   OF  THE  DEVELOPING   PERIOD        93 

erally  die  of  uremia  soon  after  birth.  If  but  one  kidney  is  affected 
the  infant  may  live ;  but  the  cystic  kidney  may  require  operation  on 
account  of  its  size  and  pressure  on  other  organs. 

Another  form  of  retention  cyst  is  hydronephrosis.  Any  chronic 
obstruction  of  the  urinary  passage  may  so  dam  the  urine  that  dis- 
tention of  the  whole  urinary  apparatus  above  the  obstruction  will 
take  place.  If  the  cause  is  phimosis,  or  a  narrow  or  impervious 
urethra,  the  bladder  first  will  feel  the  effects,  but  later  the  ureters 
and  then  both  kidneys.  If  one  ureter  only  is  obstructed,  that  portion 
of  the  passage  above  the  obstruction  and  the  pelvis  of  the  kidney 


Fig.    16.      H'ydroperinephrosis    fol- 
lowing   TRAUMATISM.      Dark     line       Fig.    17.     Same  case  after  operation, 
outlines    the    percussion     dullness.  showing  the  line  of  the  incision. 

Operation,  recovery.     Boy  aged  3^ 
years. 

dilate,  sometimes  enormously  and  with  destructive  effects  on  the 
gland  tissue  from  pressure,  as  before  described. 

A  similar,  though  more  rare,  condition  called  pseudo-hydrone- 
phrosis — but  for  which  I  have  suggested  the  better  name  of  hydro- 
perinephrosis — occurs  when  the  cyst  form.s  in  the  cellular  tissue 
just  outside  of  the  kidney.  Figs.  16  and  17  are  from  a  case  of 
this  kind.  The  patient  was  a  small  boy  of  three  and  a  half  years, 
weighing  29  pounds.  He  was  run  over  by  a  wagon,  taken  to  a 
hospital,  dismissed  as  well  after  the  first  week,  and  was  brought 
to  me  seven  weeks  later.  He  had  a  tumor  in  the  abdomen,  scanty 
urine,  and  distressing  gastric  symptoms  from  pressure.     Diagnosis, 


94  SURGICAL   DISEASES    OF    CHILDREN 

hydro-nephrosis  or  hydro-perinephrosis.  On  nephrotomy  I  found 
the  cyst,  which  contained  several  pints  of  fluid,  was  not  the  dilated 
pelvis  of  the  kidney,  but  was  outside  of  the  kidney,  although  having 
an  opening  into  the  kidney-pelvis.  The  boy  made  a  good  recovery 
and  the  kidney  resumed  its  function. 

Retention  cysts,  in  connection  with  the  urachus  and  with  the 
vitello-intestinal  duct,  also  occur. 

Diagnosis. — The  retention  cyst  is  located  in  the  situation  of  a 
secreting  or  excreting  gland.  There  are  usually  Evidences  of  les- 
sened secretion  or  excretion  from  the  affected  gland.  Pain  is  pres- 
ent if  there  is  rapid  distension  of  the  retention  cyst,  or  if  it  becomes 
infected  and  inflammation  results.  In  some  situations,  exploratory 
puncture  is  permissible. 

Prognosis  depends  on  the  vital  importance  of  the  organ  ob- 
structed and  whether  it  is  located  deeply  or  near  the  surface.  The 
danger  of  infection  has  a  bearing  on  the  prognosis.  In  case  of 
retention  cyst  within  the  abdomen  there  is  danger  of  its  rupturing 
into  the  abdominal  cavity. 

Treatment  indicated  is  to  remove  the  cause  of  the  obstruc- 
tion if  possible.  If  the  duct  is  plugged  by  concretion  the  same 
should  be  removed,  or  if  by  inflammation  the  inflammation  should 
be  treated ;  if  by  flexion  the  duct  should  be  straightened.  If  the 
obstruction  is  of  such  a  nature  that  it  cannot  be  removed,  the  indi- 
cations, are  to  withdraw  the  retained  fluid  and  establish  drainage. 
If  the  outlet  is  destroyed  the  cyst  should  be  removed.  If  adhesions 
have  rendered  that  impracticable,  its  lining  should  be  exposed  and 
cauterized  and  packed  with  gauze  and  allowed  to  close  by  gran- 
ulation. 

CONCLUDING    REMARKS 

Neither  encephalocele,  meningocele,  spina  bifida,  giantism, 
nor  acromegaly  are  properly  classed  as  tumors.  However,  it  is 
necessary  to  bear  them  in  mind  in  making  a  diagnosis.  Recalling 
now  the  varieties  of  tumor  we  have  found  most  prevalent  in  chil- 
dren, it  is  at  once  apparent  that  the  most  of  them  belong  to  the 
class  of  new  growths  arising  from  the  mesoblast — the  connective 
tissue  series..  This  we  might  almost  have  expected  when  we  con- 
sider the  intense  activity  of  the  connective  tissue  cells  during  the 
rapid-growing  time  of  childhood.  The  same  law  is  in  evidence  in 
the  lincreased  number  of  dermoids  which  make  their  appearance 
about  puberty,  when  structures  arising  from  the  epiblast  receive 
such  a  wonderful  new  impetus  in  their  development. 

But  if  the  matrix  of  a  carcinoma,  arising  also  from  the  epi- 
blast, is  present  at  birth,  what  is  the  inhibiting  power  that  prevents 
its  development  in  so  many  cases  until  middle  Hfe  or  past?     It  is 


SURGICAL  PATHOLOGY  OF  THE  DEVELOPLNG  PERIOD  95 

true  that  babies  and  even  youths  have  not  experienced  the  trauma- 
tisms and  irritations  which  help  to  produce  tumor  growth  and 
induce  malignancy.  Children  have  not  followed  dusty  or  irrita- 
ting occupations,  such  as  chimney-sweeps,  millers,  charworkers, 
et  cetera;  nor  have  they  so  frequently  acquired  scar  tissue,  either 
by  wounds  through  normal  tissues  or  by  the  attempted  removal  of 
benign  growths  with  caustics,  which  only  partly  remove  them  and 
leave  a  part,  together  with  irritated  or  depressed  surrounding  cells. 
Children  are  less  apt  to  have  syphilitic  ulcerations,  lupus,  chronic 
ulcers,  old  sinuses,  which  are  prone  to  develop  carcinoma.  Their 
genital  organs  have  not  undergone  repeated  congestion  nor  inflam- 
mation nor  irritation,  as  those  of  adults.  How  much  have  these 
facts  to  do  with  the  scarcity — the  almost  entire  absence — of  epi- 
thelioma and  scirrhus  in  the  young?  And  how  much  is  due  to  that 
physiological  resistance  of  normal  cells  entrenched  in  their  proper 
surroundings  against  the  invasion  and  development  of  foreign  or 
of  abnormal  cells?  Very  interesting  studies,  for  example  those  of 
Tyzzer  ^  tend  to  show  that  in  the  experimental  production  of  tumors 
by  the  inoculation  of  tumor  tissue,  it  is_  the  growth  of  the  trans- 
planted cells  and  not  the  introduction  of  a  virus  that  produces  the 
tumor.  With  certain  kinds  of  tumors  the  continuation  of  the 
growth  is  not  dependent  upon  peculiar  conditions  in  the  tissues  to 
which  they  are  transplanted.  With  other  kinds  peculiar  conditions 
are  essential ;  for  the  tumor  will  grow  if  transplanted  into  other 
parts  of  the  same  individual,  but  not  if  transplanted  to  other  in- 
dividuals. The  nature  of  a  tumor  growth  depends  upon  the  biologic 
character  of  its  cells,  just  as  in  Cohnheim's  experiments  before  cited, 
normal  cells,  dislocated,  still  tend  to  produce  their  kind.  Re- 
membering the  power  of  normal  cells  to  resist  abnormal  or  hetero- 
geneous growth,  and  the  remarkably  great  reproductive  power  of 
embryonic  cells,  as  shown  by  Cohnheim  and  Maas,  it  would  be  of 
extreme  interest  to  perform  a  series  of  experiments  to  ascertain 
whether  the  physiological  resistance  to  such  foreign  cell  encroach- 
ment is  different  in  the  young  subject  from  what  it  is  in  the  old. 

There  is  another  field  for  further  study  in  the  pathology  of 
the  tumors  of  children.  Are  they  more  or  less  subject  to  infection, 
to  ulceration,  or  do  they  behave  differently  under  irritation  or 
traumatism  than  the  same  variety  of  tumor  in  the  adult?  Are  the 
degenerative  changes  different  in  the  young  subject?  Compare 
calcification,  ossification,  caseation,  amyloid,  colloid,  mucoid  and 
fatty  changes  in  the  young  with  those  in  the  old.  Is  there  any 
different  behavior  of  the  lymphatic  system  toward  tumors  in  the 
young?  Are  their  tumors  more  or  less  liable  to  interstitial  hemor- 
rhage or  thrombosis? 

1  Tyzzer.     Boston  Med.  &  Surg.  Jour.,  1909,  161,  p.  103. 


CHAPTER  III 

CONCERNING   CERTAIN   CONSTITUTIONAL  DISEASES 
Hemophilia — Rachitis  or  Rickets — Infantile  Scorbutus. 

HEMOPHILIA 

Hemophilia  is  an  hereditary  disease  in  which  there  is  a  ten- 
dency to  bleed  persistently  from  the  slightest  wound.  Alarming 
and  fatal  hemorrhages  have  occurred  after  operations  upon  or  in- 
juries to  "  bleeders,"  as  those  afflicted  with  this  disease  are  called. 
Hemophilia  may  sometimes  be  traced  through  seven  or  eight  genera- 
ations,  descending  to  the  males  through  the  females,  the  females 
themselves  being  seldom  affected.  But  it  often  skips  a  generation, 
or  follows  only  one  branch  of  a  family  in  its  descent. 

The  following  cases  from  among  those  which  have  come  under 
my  own  observation  occurred  in  two  generations  in  the  S.  family. 
They  so  well  illustrate  the  characteristics  of  this  peculiar  disease 
that  I  beg  leave  to  introduce  them  at  this  point. 

Mrs.  S,  knows  of  no  bleeding  tendency  among  her  immedi- 
ate ancestors ;  and,  although  she  had  four  brothers  and  two  sisters, 
who,  in  the  aggregate,  were  parents  to  thirteen  children,  seven 
boys  and  six  girls,  none  of  them  of  either  sex  have  yet  shown 
hemophilia.  The  disease  has  followed  this  one  branch  of  the 
family.  Mrs.  S.  herself  has  several  times  had  hemorrhage  after 
slight  injury — for  instance,  bleeding  three  days,  in  spite  of  rem- 
edies, whenever  she  had  a  tooth  extracted.  She  flowed  abundantly, 
but  not  dangerously,  at  each  menstrual  period  and  childbirth.  She 
was  married  twice,  by  the  first  husband  having  one  daughter,  and 
by  the  second,  two  sons  and  one  daughter.  The  girls  were  never 
affected  by  hemophilia.  But  the  boys,  from  the  second  or  third 
year  on,  showed  extensive  contusions  from  the  slightest  bump,  and 
at  about  their  eighth  year  got  joint  swellings,  especially  of  knees 
and  elbows.  These  swellings  were  accompanied  with  pain,  tender- 
ness, discoloration,  and  loss  of  function,  each  attack  lasting  ten  to 
fourteen  days  and  then  subsiding  somewhat.  But  the  joint  attacks 
finally  disabled  them  from  walking  or  work,  extension  of  either 
legs  or  arms  being  impossible  on  account  of  swelling  and  tender- 
ness. (See  Fig.  i8.)  When  H.,  the  elder  brother,  was  eighteen 
years  of  age,  a  surgeon  tried  to  straighten  the  right  knee  by  tenot- 

96 


CONCERNING   CERTAIN    CONSTITUTIONAL   DISEASES        97 

omy.  The  hemorrhage,  although  not  profuse  at  the  time  of  the 
operation,  was  very  obstinate.  The  first  dressing  was  left  on  three 
days.  Then  the  leg  and  thigh  were  found  black  and  swollen,  and 
removal  of  the  bandages  was  followed  by  a  gush  of  blood.  This 
was  repeated,  regardless  of  all  remedies,  and  he  died  eleven  days 
after  the  operation. 
The  younger  brother, 
G.,  gradually  grew 
worse.  In  his  seven- 
teenth year  his  knees 
were  flexed  to  nearly  a 
right  angle,  and  could 
be  moved,  the  right 
about  thirty  and  the 
left,  fifteen  degrees. 
Elbows  movable  thirty- 
five  degrees,  all  with 
great  pain.  Suffered 
severe  pain  at  these 
points  and  in  right 
shoulder.  Was  mo- 
rose, peevish  and  shy, 
and  addicted  to  mor- 
phine. A  slight  injury 
to  the  right  arm  now 
produced  an  immense 
swelling,  extending 
nearly  from  shoulder- 
to  elbow.  After  five 
weeks  the  swelling  be- 
came tense,  black,  and 
oozed  blood,  then 
opened  and  bled  three 
days,  when  he  died. 

Mrs.  S.'s  daughter  (by  first  husband,  as  before  stated,  thus 
proving  transmission  by  the  mother)  married  and  had  three  chil- 
dren. The  eldest  is  a  boy,  B.  B.  (See  Fig.  19,  taken  when  he 
was  eleven  years  old.)  He  first  got  swelling  and  tenderness  of 
joints  at  one  and  one-half  years  and  early  showed  the  tendency  to 
acquire  contusions,  which  would  appear  four  or  five  days  after 
injury  and  remain  swollen,  discolored,  and  tender  for  weeks. 
When  two  years  old  a  slightly  cut  finger  bled  four  days.  At  four 
years  he  accidentally  bit  his  tongue  and  bled  three  weeks.  A  small 
punctured  wound  of  the  chin  bled  nine  days.  A  few  years  later 
a  small  cut  on  the  brow,  received  while  coasting,  was  repaired  with 


Fig  18.  Hemophiliac  Brothers.  Com- 
plete extension  of  knees  or  elbows  im- 
possible on  account  of  swelling,  tender- 
ness and  hemorrhages.  The  elder 
brother,  aged  18,  died  eleven  days  after 
an  injudicious  attempt  to  straighten  one 
knee  by  tenotomy.  The  younger  brother 
died  at  17  years  from  repeated 
spontaneous  hemorrhages.  These  two 
brothers  are  uncles  to  the  hemophiliac 
boy  shown  in  Fig.   19. 


SURGICAL  DISEASES    OF   CHILDREN 


two  sutures.     Six  days  later  immense  hemorrhage  took  place.     A 
surgeon  who  was  called  in  "  did  not  believe  in  '  bleeders.' "     He 

enlarged  the  wound  to 
search  for  a  supposed 
bleeding  vessel.  The 
hemorrhage  which  fol- 
lowed could  not  be  con- 
trolled even  with  forceps, 
which  were  left  in  the 
wound,  but  which  broke 
away,,  bringing  slough- 
ing tissues,  ligatures, 
and  sutures.  All  known 
styptics  were  used,  but 
oozing  continued  to  satu- 
rate dressings  for  five 
days,  when  the  boy  was 
nearly  dead.  The  hem- 
orrhage stopped  spon- 
taneously and  the  wound 
healed,  leaving  the  scar 
seen  on  the  temple  in 
Fig.  19.  He  was  a  tall 
boy  at  eleven,  standing 
59  inches.  Observe  the 
large  knee  joints  and  the 
discolored  contusions  up- 
on the  legs.  His  younger 
brother,  H.  B.,  at  the  age 
of  six  years,  has  never 
shown  anything  abnor- 
mal, even  after  cuts  and 
bruises.  The  third  child, 
a  girl  of  three,  has  had 
injuries,  but  showed  no 
symptoms  of  hemophilia. 
The  nature  of  the  dis- 
ease is  unknown.  Sus- 
pected changes  in  the 
blood  or  on  the  blood- 
vessels have  not  been 
proven.  This  disease 
is  not  to  be  confounded  with  the  hemorrhagic  disease  of  the 
new-born,  the  various  forms  of  purpura,  the  hemorrhages  that 
sometimes  appear  in  hereditary  lues,  nor  with  scurvy.    It  does  not 


Fig.  19.  Hemophiliac  boy.  Nephew  to 
the  hemophiliac  boys  shown  in  Fig.  18. 
The  deep  scar  on  the  brow  came  from 
a  sHght  injury  which  nearly  cost  him 
his  life.  The  large  knee  joints  and 
right  elbow  and  the  discolored  con- 
tusions upon  the  legs  are  well  shown. 


CONCERNING   CERTAIN    CONSTITUTIONAL   DISEASES        99 

usually  make  its  appearance  till  in  the  second  year,  and  the  ten- 
dency to  bleed  may  be  finally  lessened  in  those  cases  that  survive 
to  adult  life.  The  arthritic  inflammations  resembling  rheumatism 
are  common  accompaniments.  Some  patients  bleed  periodically.  (10) 
Treatment. — The  ordinary  means  for  hemostasis  may  be  tried. 
Pressure  forceps  or  ligatures,  compression,  heat,  cold,  tannin,  alum., 
Monsell's  solution,  cupric  sulphate,  collodion,  adrenalin,  and  other 
styptics.  The  persistent  hemorrhage  seems  to  be  capillary  and  to 
defy  stasis.  Ligatures  and  sutures  are  apt  to  slough  secondarily. 
Internal  medication  has  little  or  no  effect.  Many  drugs  have  been 
tried,  including  tannic  and  gallic  acids,  lead  actate,  ergot,  hama- 
melis,  calcium  chloride,  adrenalin,  and  even  thyroids  and  many 
others  old  and  new,  hydrastine  hydrochlorate,  stypticin  (Fischer). 
But  the  hemorrhage,  when  it  ceases,  usually  does  so  spontaneously. 

(11) 

^      ^  RACHITIS  OR  RICKETS 

This  is  a  constitutional  disease  sometimes  classed  as  a  disorder 
of  development,  sometimes  as  a  disease  of  the  bones,  but  more  cor- 
rectly a  disease  of  nutrition  affecting  not  only  the  bones  and  teeth, 
but  the  nervous  system,  the  muscles,  aponeuroses  and  ligaments, 
the  mucous  membranes  and  the  lymphatics,  and  to  some  extent  the 
internal  organs,  especially  the  spleen.  The  direct  effects  upon  the 
skeleton  attributable  to  rickets,  and  its  indirect  influence  in  the 
causation  of  hernia  and  lymphadenitis,  which  are  not  so  obvious, 
are  the  principal  reasons  for  its  place  as  a  surgical  disease.  Also 
its  resemblance  to  other  acute  and  chronic  diseases  of  bone,  peri- 
osteum and  cartilage,  and  to  diseases  of  development. 

Etiology. — The  exact  etiology  of  rickets  is  obscure.  Its  pro- 
duction is  probably  a  complex  process.  Broadly  speaking,  the  cause 
is  found  in  faulty  diet,  and  especially  in  a  diet  lacking  in  fat  and 
proteid  elements,  the  lack  of  fat  being  the  more  serious  of  the  two. 
For  a  time  it  was  claimed  that  an  excess  of  carbo-hydrates  was  the 
cause,  acting  by  producing  excess  of  lactic  acid,  which  interfered 
with  the  assimilation  or  the  deposition  of  lime  salts.  But  it  is  prob- 
ably the  lack  of  essential  elements  rather  than  an  excess  of  any  one 
element.  But  besides  the  effects  of  faulty  diet  there  is  undoubtedly 
a  causative  relationship  in  bad  hygienic  surroundings,  especially 
overcrowding,  lack  of  sunlight  and  fresh  air,  and,  as  it  seems  to 
me,  lack  of  warmth — not  merely  warmth  of  climate,  but  warmth  by 
clothing.  As  might  be  expected  after  these  premises,  rickets  is 
most  frequently  found  in  infants  artificially  fed,  although  it  can 
occur  in  the  breast-fed ;  and  in  the  children  of  the  poor  in  large 
cities,  although  it  may  occur  under  opposite  circumstances.  Rickets 
prevails  most  in  the  temperate  zones.  It  is  exceedingly  common 
in   England   and   quite   common   in   the   United    States,   especially 


100  SURGICAL  DISEASES   OF  CHILDREN 

among  the  immigrant  classes  and  their  immediate  descendants. 
Our  most  marked  cases  are  among  the  Negroes  and  ItaHans,  though 
slighter  degrees  will  often  be  found,  if  looked  for,  among  Ameri- 
cans. Heredity  has  probably  nothing  to  do  with  the  direct  causa- 
tion of  rickets,  but,  like  alcoholism,  tuberculosis  or  syphilis,  it  may 
produce  offspring  of  poor  resisting  power,  although  Siegert  has 
drawn  attention  to  rachitic  and  non-rachitic  families  living  in  ex- 
actly the  same  unhygienic  conditions.  The  presumption  that  rick- 
ets is  but  an  evidence  of  remote  syphilis  is  negatived  by  the  fact 
that  the  earlier  children  of  a  family  show  most  evidence  of  a  syphi- 
litic taint,  while  with  rickets  it  is  the  later  children  who  are  most  apt 
to  have  the  disease. 

Lesions. — The  lesions  are  most  marked  in  the  bones.  The 
rachitic  bone  is  abnormally  flexible  and  soft  if  examined  in  the 
active  stage  of  the  disease,  before  "  eburnation  "  begins.  The  long 
bones  are  too  smoothly  cylindrical,  somewhat  lacking  the  well- 
defined  borders,  tuberosities,  processes,  and  surfaces  which  mark 
the  normal  bone.  The  periosteum  is  thickened  and  hyperemic.  The 
epiphyseal  cartilages  are  enlarged,  especially  those  at  the  lower  end 
of  radius  and  tibia.  One  of  the  peculiar  features  of  rickets  is  that 
there  is  no  certainty  as  to  which  bones  will  exhibit  the  most  severe 
lesions,  those  of  the  upper  or  lower  extremity,  the  ribs,  or  the  cra- 
nial bones.  The  enlarged  epiphyses  result  from  an  excessive  pro- 
liferation of  cartilage  cells  deposited  in  imperfect  histological  ar- 
rangement, the  hyperemic  periosteum  also  proliferating  bone.  But 
in  neither  situation  is  the  transition  to  norm.al  bone  effected,  the 
amount  of  calcium  salts  it  contains  being  reduced  from  30  to  50 
per  cent.  Meanwhile,  the  medullary  canal  has  been  increased  in 
size  by  absorption  of  its  inner  layers,  and  the  bone  marrow  is 
reddened  with  an  increase  of  red  blood  cells.  The  epiphyseal 
cartilage  is  thickened  to  sometimes  four  or  five  times  its  normal 
thickness  and  widened  as  much  as  a  fourth  or  half  beyond  its  nor- 
mal width,  is  softer  than  normal,  and  the  zone  of  growth  is  darker 
and  bluish  in  color.  The  line  of  the  junction  between  cartilage 
and  diaphysis,  which  normally  is  straight,  here  presents  an  irregular 
or  indentated  appearance.  When  examined  with  the  microscope 
it  is  seen  that  this  border  line  of  the  process  of  calcification,  which 
should  be  straight,  is  interrupted  by  projection  through  it  into  the 
cartilage  areas  of  calcified  ground  substance  or  osteoid  foci,  in 
which  medullary  spaces  are  being  formed  ;  and  on  the  other  side, 
islands  or  foci  of  calcified  or  decalcified  cartilage  are  seen.  Thus  the 
bony  and  cartilaginous  tissues  are  irregularly  intermingled  across  the 
epiphyseal  line.  The  osteoid  tissue — that  is,  newly  formed  bone, 
which  is  still  decalcified — is  thicker  than  it  should  be,  the  trabecular 
spaces  remain  large,  and  the  bone  spongy  and  never  properly  cal- 


CONCERNING  CERTAIN   CONSTITUTIONAL  DISEASES        loi 

cified.  The  flat  bones — for  example,  the  frontal  protruberances  or 
bosses — present  the  same  process  as  has  been  described  as  taking 
place  beneath  the  periosteum,  namely,  excessive  formation  of  osteo- 
genetic  layers  upon  the  surface  of  the  bone,  the  deposition  of 
osteoid  substance,  and  deficient  deposition  of  calcium  salts,  so  that 
the  bony  trabeculse,  while  calcified  within,  are  lacking  calcium  at 
the  periphery  and  remain  soft,  causing  the  characteristic  flexibility 
of  the  bone  with  its  visible  hyperemia  on  section.  The  pathologists 
have  not  yet  decided  whether  these  changes  are  of  the  nature  of 
inflammation  or  merely  of  faulty  nutrition.  In  the  course  of  three 
to  fifteen  months  the  condition  of  inflammation,  if  it  be  such,  or 
the  process  of  irregular  proliferation,  comes  to  an  end  and  is 
replaced  by  a  process  of  ossification.  The  vascularity  subsides,  and 
calcium  salts  are  deposited,  in  some  cases  being  substituted  for 
cartilage.  The  bone  resulting  is  condensed  and  hardened  to  a 
density  exceeding  that  of  normal  bone,  though  never  having  the 
normal  structure.  In  the  meantime  various  deformities  may  have 
been  produced,  which  will  be  described  in  the  section  on  symptoms, 
and  various  lesions  of  tissues  other  than  bone  cartilage  and  peri- 
osteum have  been  present  in  varying  degrees.  The  ill-nourished 
muscles  have  become  relaxed  or  atrophied.  The  bronchial  mucous 
linings  and  the  lungs  show  the  effects  of  repeated  catarrhal  inflam- 
mations. The  lungs  may  also  have  become  impervious  where 
pressed  upon  by  the  collapsed  thoracic  walls.  The  spleen  has  been 
enlarged,  but  not  degenerated,  and  subsides  with  the  cessation  of 
the  disease.  Chronic  catarrhal  inflammation  of  the  gastro-intestinal 
organs,  with  over-distension  of  weakened  musculature,  has  caused 
dilatation.    The  lymph  nodes  are  enlarged. 

Lamellar  cataract  is  claimed  by  some  to  be  a  result  of  rachitis, 
although  such  a  relationship  is  denied  by  Hutchinson.  The  erup- 
tion of  the  teeth  is  delayed  and  they  appear  irregularly  as  to  time 
and  as  to  position  in  the  alveolar  process.  Occlusion  is  imperfect. 
The  teeth  become  prematurely  discolored  and  carious.  Their  sur- 
faces are  grooved  and  striated.  Their  edges  rapidly  erode,  often 
being  notched  thereby.     (See  Figs.  20  and  21.) 

Age  of  Incidence. — The  age  of  incidence  most  frequently  is 
between  the  sixth  and  fifteenth  month,  according  to  Holt,  but  one 
is  sure  it  may  come  somewhat  earlier  or  later.  Cases  of  congenital 
rickets  and  of  late  rickets,  beginning  between  the  sixth  and  tenth 
years,  have  been  reported,  but  must  be  very  rare.  In  twenty  years' 
dispensary  service  I  do  not  recall  a  case  in  which  it  was  proven 
to  have  begun  after  the  period  of  childhood.  Possibly  some  cases 
of  knock-knee  or  bowed  legs  from  relaxed  ligaments  or  other  causes 
have  occasionally  been  attributed  to  rickets. 

Early  Symptoms. — The  early  symptoms  should  be  mentioned 


102 


SURGICAL  DISEASES    OF   CHILDREN 


separately,  because  the  early  detection  of  the  condition  is  important. 
Almost  always  the  first  symptom  noticed  by  the  mother  is  either 

restlessness  at  night  and 
kicking  off  the  bedclothes, 
or  else  head  sweating  dur- 
ing sleep.  The  reason  for 
this  kicking  of  the  clothes 
is  unknown.  Some  have 
thought  it  due  to  the  fre- 
quent indigestion  and  reflex 
disturbances.  The  profuse 
sweating  of  the  head  has 
been  attributed  to  the  habit 
of  rolling  or  rubbing  the 
head  upon  the  pillow,  which 
seems  improbable.  The 
restlessness  and  head- 
sweating  may  continue  for 
weeks  or  months  before  any 
other  symptoms  are  noticed. 
Beading  of  the  ribs  almost 
Fig.  20.  Rachitic  teeth.— Dr.  I.  A.  Abt.  always  is  present  as  an  early 
sign,  but  is  not  always  pres- 
ent in  a  marked  degree. 
Constipation  is  present  in 
most  cases,  but  is  so  com- 
mon a  symptom  in  other 
conditions  as  to  attract  little 
attention  toward  the  rachi- 
tis. Cranio-tabes  is  among 
the  early  signs. 

Other  Symptoms. — Be- 
sides the  restlessness  at 
night  there  are  other  nerv- 
ous symptoms,  such  as  a 
predisposition  to  general 
convulsions  upon  the  slight- 
est provocation,  such  as 
disorder  of  the  digestive 
organs,  laryngismus  stridu- 
lus or  tetany,  or  local  mus- 
cular spasm.  Pain  or  ten- 
derness are  mentioned,  but 
belong  rather  to  scurvy.  The  mucous  membranes  suffer  with  re- 
peated and  easily  induced  attacks  of  catarrhal  inflammations,  such 


Fig.  21.  Rachitic  teeth. — Dr.  I.  A.  Abt. 


CONCERNING   CERTAIN    CONSTITUTIONAL   DISEASES        163 

as  croup,  bronchitis,  broncho-pneumonia ;  or  of  gfastric  and  intesti- 
nal catarrhs.  Such  attacks  are  not  only  easily  induced,  but  obsti- 
nate to  treat. 

General  Condition. — The  general  condition  is  not  always  that 
of  emaciation.  Many  cases  appear  fat,  some  are  marasmic,  all  poor 
in  muscular  tissue.  Practically  all  are  anemic.  Any  of  the  usual 
forms  of  anemia  may  be  present,  and  worse,  according  to  the  sever- 
ity of  the  case.  Hypertrophied  tonsils  and  adenoids  are  very  com- 
mon in  rickety  chil- 
dren ;  and  the  obstruc- 
tion they  cause  adds 
greatly  to  the  general 
debility  and  increases 
the  deformities  of  the 
chest.  (See  Chapter  on 
Obstructions  of  the  Air 
Passages.)  Enlarged 
lymphatic  glands  of  the 
neck  are  common  ac- 
companiments. 

Deformities.  —  The 
deformities  of  rickets 
are  very  numerous. 
They  are  not  all  always 
present,  nor  do  they  al- 
ways appear  in  the  same 
degree  of  deformity  in 
equally  severe  cases. 
Thus,  in  three  cases  of 
equal  severity,  one 
might  have  the  worst 
deformity  in  the  chest, 
another  be  most 
marked  in  the  upper  ex- 
tremities, and  the  third  show  the  disease  most  strikingly  in  de- 
formity of  the  lower  extremities.  Some  cases  may  present  all  the 
known  evidences  of  the  disease.  Several  of  them  may  be  seen  in 
Fig.  23,  seventeen  months  old.  Observe  the  large  head,  the  narrow 
chest,  the  distended  abdomen,  and  symmetrical  deformities  of  the 
extremities,  namely,  bowed  forearms,  enlarged  radial  and  lower 
tibial  epiphyses,  and  the  tibiae  curved  convex  anteriorly.  We  will 
consider  the  deformities  separately. 

The  head  appears  too  large ;  but  this  may  appear  more  so  by 
comparison  with  the  chest,  for  it  may  not  be  so  large  by  measure- 
ment.   Some  actual  enlargement  is  usual.    This  is  not  due  to  expan- 


FiG.  22.  Typicai,  teeth  of  hereditary 
SYPHILIS  (Hutchinson  teeth).  Also 
shows  the  bossed  frontal  bones  and  the 
flat  nose.  Had  snuffles  and  specific 
rashes  when  a  babe,  and  family  history 
of  syphilis.     Girl  aged  8  years. 


104 


SURGICAL   DISEASES    OF   CHILDREN 


sion  from  within,  as  in  hydrocephalus,  but  to  the  thickening  of  the 
cranial  bones,  which  is  most  marked  upon  the  frontal  and  parietal 
bones.  These  enlargements,  together  with  a  flattening  upon  the 
top  and  behind,  give  the  head  a  somewhat  square  shape  which  is 
different  from  the  globular  enlargement  of  hydrocephalus.     The 

anterior  fontanel  may  re- 
main open  until  the  second 
or  third  year,  and  when 
ossified  remain  flattened 
or  even  depressed.  The 
sutures  may  remain  open 
more  than  a  year,  and 
when  closed  still  be  very 
perceptible.  Craniotabes, 
a  parchment-like  crack- 
ling or  wrinkling  sensa- 
tion tmder  slight  pressure 
by  the  finger-tips  over  the 
occipital  and  parietal 
bones,  may  be  present.  It 
is  due  to  a  thinning  of  the 
bones  in  spots,  and  is  not 
pathognomonic  of  rickets, 
being  found  also  in  heredi- 
tary syphilis.  The  veins 
of  the  scalp  may  be 
prominent,  but  not  to  that 
degree  usual  in  hydro- 
cephalus. The  head  retains 
to  a  great  degree  its  char- 
acteristic deformity  after 
recovery,  although  the 
swelling  of  the  bones  di- 
minishes somewhat.  Den- 
tition is  delayed,  espe- 
cially if  rickets  begins 
early  before  teething  has 
begun. 

The  most  constant  sign  upon  the  thorax  is  the  "  rickety 
rosary  " — beaded  ribs — an  enlargement  of  the  epiphyseal  cartilages 
at  the  costo-chondral  junctions.  They  are  well  shown  in  Fig.  26, 
which  is  a  very  marked  case  in  a  babe  fourteen  months  old.  Bead- 
ing is  by  no  means  always  so  prominent.  It  may  be  discovered  only 
by  palpation.  Beading  takes  place  upon  the  inside,  as  well  as  upon 
the  outside,  of  the  thorax,  or  only  upon  the  inside.  The  most  seri- 
ous deformity  of  the  thorax,  so  far  as  its  effect  upon  health  is 


Fig.  23.  Rachitis.  Large  head,  nar- 
row chest,  distended  abdomen.  Sym- 
metrical deformities  of  extremities, 
namely,  bowed  forearms,  enlarged 
radical  and  lower  tibial  epiphyses,  and 
the  tibiss  curved  convex  anteriorly. 
17  mos.  old 


CONCERNING   CERTAIN    CONSTITUTIONAL   DISEASES        105 

concerned,  is  the  flattening  in  of  its  sides.  This  is  produced  by 
atmospheric  pressure  upon  the  yielding  chest  walls,  which  are  soft- 
est just  where  the  ribs  and  cartilages  join,  but  present  more  resist- 
ance in  the  sternum  which  stands  forward.  A  frequent  deformity 
is  a  flaring  outward  of  the  lower  part  of  the  thorax,  caused  by  the 
distension  of  the  abdomen,  and  often  persisting  in  cases  long  recov- 
ered from  active  rickets.  The  "  rachitic  girdle  "  is  a  groove  or 
depression  extending  across  the  chest  from  side  to  side,  just  above 
its  lower  border.  The  "  funnel-chest "  is  seen  in  Fig.  180,  thirteen 
months  old.  The  clavicles  may  be  enlarged  at  their  ends  and  the 
normal  curve  forward  exaggerated  at  the  inner  third.  This,  with 
the  curving  of  the  spine,  causes  the  neck  to  appear  short. 

Distension  of  the  abdomen  is  a  common  and  pronounced  symp- 
tom in  most  cases.  "  Pot-belly,"  or  "  potato-belly,"  comes  early. 
It  is  produced  by  the  faulty  digestion,  with  formation  of  gases,  and 
the  constipation,  or  alternating  diarrhea,  which  act  upon  weakened 
and  toneless  muscular  walls  and  stretched-out  aponeuroses.  They, 
like  the  stomach  and  colon,  become  permanently  dilated.  The 
enlargement  is  uniform  and  tympanitic.  The  linea  alba  stretches  to 
a  thin,  wide  ribbon  between  the  two  recti,  and  umbilical  hernia  is 
common.     It  may  be  seen  in  Figs.  23,  24  and  26. 

The  characteristic  rickety  deformity  of  the  spine  is  well  seen 
in  Fig.  24.  It  is  a  rounded  kyphosis  or  posteriorly  convex  curve, 
extending  usually  from  the  mid-dorsal  region  to  the  top  of  the 
sacrum.  It  will  be  further  described  in  the  chapter  on  the  spine. 
It  is  not  present  in  all  cases,  even  in  children  who  sit  or  stand. 

In  the  upper  extremity  the  most  common  deformity  is  swell- 
ing of  the  radial  epiphyses,  especially  at  the  wrist.  Bowing  of 
the  forearms  with  the  convexity  on  the  extensor  side  is  frequent. 
Fib  25  is  a  good  example,  also  Fig  24.  Fig.  25  also  shows  a 
characteristic  attitude  of  the  rickety  child,  sitting  cross-legged  and 
leaning  forward  on  the  hands,  thus  bending  the  forearms,  and  also 
putting  curves  in  the  spine  and  the  legs,  and  sometimes  in  the 
thighs  and  pelvis.  This  case  also  exhibits  the  big  belly  and  the  beaded 
ribs.  Such  children  do  not  want  to  be  moved  or  changed  to  any 
other  position.  The  humeri  are  not  so  frequently  bowed,  yet  they 
may  be  so,  or  enlarged  at  their  epiphyses.  Deformities  of  the  upper 
extremities  are  apt  to  be  symmetrical.  Bowing  may  partly  dis- 
appear. Enlarged  radial  epiphyses  are  apt  to  show  through  life. 
The  lower  extremities  also  yield  to  muscular  tension  and  to  weight, 
besides  exhibiting  the  swelling  of  the  cartilages.  The  thigh  and 
leg  bones  yield  in  various  directions,  producing  the  bow-legs,  bandy- 
legs,  saber-legs  (with  the  tibiae  convex  anteriorly,  as  seen  in  Fig. 
24),  or  the  corkscrew-legs,  which  are  bent  in  several  directions. 
(See  also  chapter  on  Rickety  Deformities.) 

Rickets  runs  a  chronic  course,  and  recovers  unless  complica- 


io6 


SURGICAL   DISEASES    OF   CHILDREN 


tions  prove  fatal.  The  active  condition  continues,  according  to 
Holt,  from  three  to  fifteen  months.  It  ceases  when  the  conditions 
which  caused  it  are  changed.  Often  it  is  weaning  or  a  change 
to  more  suitable  food  and  more  outdoor  life  that  terminates  the 

disease.  The  symptoms  subside 
in  somewhat  the  same  order 
that  they  came,  the  nervous 
manifestations  first  and  the  de- 
formities last  if  at  all.  There  is 
usually  some  deformity  which 
requires  mechanical  interfer- 
ence. With  this  we  shall  deal 
in  the  appropriate  section. 

Diagnosis.  —  The      diagnosis 
is  easy  in  a  typical  case ;  but  in 
the     slighter    cases    and    early 
stages   it  may   be   necessary   to 
examine    for   all   the   symptoms 
that    have    been    here    enumer- 
ated.   By  the  time  the  case  with 
bony  changes  is  brought  to  the 
surgeon  the  nature  of  the  diffi- 
culty should  be   distinguishable. 
The      enlargement      of      the 
head     may     be     mistaken     for 
hydrocephalus.     But  this  latter 
has    the    head    globularly     ex- 
panded, with  the  eyes  depressed 
in    their    orbits,    or    strabismus, 
and    often    symptoms    of    brain 
Fig.  24.     Typical  Rachitis.     Large   pressure,  and  the  fontanels  not 
square    head,    big    belly,    rounded   only    open    but    bulging.      Ra- 
kyphos,   enlarged   radial    epiphyses,      ,  ., .      ,  1       j        -^i 

and  bowed  tibise.  chitis   has   a    square    head    with 

flat  vertex,  and  craniotabes ; 
and  no  signs  of  intracranial  pressure.  The  rickety  curved  spine 
may  be  mistaken  for  the  kyphosis  of  tubercular  spinal  disease.  But 
the  rickety  spinal  curve  is  rounded  and  disappears,  or  almost  dis- 
appears, with  the  flexibility  test.  The  kyphosis  of  caries  is  angular 
and  rigid,  not  yielding  with  extension  or  backward  flexion.  Rickets 
and  scurvy  may  be  confused.  Scurvy  has  the  greatest  tenderness 
at  the  epiphyses  of  the  lower  extremities,  ecchymoses  in  the  skin, 
hemorrhages  beneath  the  periosteum,  and  spongy  gums.  Rickets 
presents  no  marked  tenderness  excepting  about  the  ribs,  and  no 
gum  lesions.  Achondroplasia  may  be  mistaken  for  the  more  com- 
mon disease,  rickets.     But  achondroplasia  is  congenital ;  the  head 


CONCERNING  CERTAIN   CONSTITUTIONAL   DISEASES        107 


is  dwarfed  at  the  base,  besides  being  expanded  above ;  the  long 
bones  have  failed  to  grow  in  length,  are  not  curved,  and  widen 
abruptly  at  the  epiphyses.  Rickets  comes  in  the  second  six  months 
of  life,  with  its  nervous,  catarrhal  and  bone-deforming  train  of 
symptoms.  Syphilitic  osteochrondritis,  the  pseudo-paralysis  of 
hereditary  syphilis,  may  be  taken  for  rachitis.  But  the  former 
comes  usually  in  the  first  few  weeks  of  life.  It  presents  a  swelling 
of  perhaps  one  lower 
epiphysis  of  femur  or 
humerus.  The  swelling  is 
painful.  Separation  of 
the  epiphysis  may  occur. 
Late  syphilis,  correspond- 
ing to  tertiary,  affects  the 
shaft  rather  than  the  ex- 
tremities. Rickets,  as  has 
been  said,  seldom  comes 
before  the  second  half 
year  of  life;  the  bone 
lesions  are  apt  to  be  multi- 
ple and  symmetrical,  and 
almost  painless.  In  syph- 
ilis and  in  scorbutus  the 
therapeutic  test  is  generally 
conclusive. 

The  differentiation  of 
rickets  from  some  forms 
of  paralysis  should  be  al- 
luded to,  especially  with 
respect  to  the  common 
forms,  poliomyelitis  and 
paraplegia.  The  apparent 
paralysis  involves  many 
muscles,  there  is  no  rig- 
idity or  coldness.  The  re- 
flexes and  muscle  reac- 
tions are  present.  In 
paralysis  from  poliomyelitis  the  paralysis  is  limited  to  certain  mus- 
cles or  muscle  groups ;  the  parts  are  cold,  perhaps  wasted,  and  re- 
flexes diminished  and  reactions  altered.  With  cerebral  palsy  there 
is  rigidity  of  the  lower  extremities,  exaggerated  patellar  reflexes 
and  likely  cerebral  symptoms. 

Treatment. — Many  cases  coming  to  the  surgeon  are  past  the 
stage  when  anything  but  operative  or  mechanical  means  will  be 
of  any  service,  the  damage  haviing  been  done  and  remaining,  al- 


FiG.  25.  Characteristic  attitude  of 
RACHITIC  CHILD,  sitting  crosslcgged 
and  leaning  forward,  resting  weight 
upon  the  arms  which  has  caused  the 
forearms  to  become  bowed.  This  po- 
sition often  curves  also  the  legs  and 
the  spine,  and  sometimes  the  thighs 
and   the   pelvis. 


io8 


SURGICAL  DISEASES    OF   CHILDREN 


though  the  cause  is  no  longer  active.  Others  may  fortunately  be 
brought  earlier  in  the  case,  when  in  addition  to  his  osteotomes  and 
osteoclasts,  his  tenotomes,  casts  and  braces,  the  surgeon  should 
have  recourse  to  diet,  hygienic  measures,  and  perhaps  drugs.  Briefly, 
these  consist  in  the  withdrawal  of  the  food  that  has  occasioned  the 
disease.  If  the  infant  is  nursing  late  it  should  be  weaned.  Often 
it  will  not  feed  properly  until  this  is  done.  The  use  of  carbohy- 
drates, namely,  starches  and  sugars,  and  all  canned  or  proprietary 
foods,  should  be  prohibited  or  limited.     In  their  stead  the  child 


Fig 


Beading  of  the  ribs  from  rachitis.     Note  also  the  flabby  muscles, 
big   belly   and   umbilical   hernia. 


should  have  all  it  can  digest  of  fats  and  nitrogenous  foods,  namely, 
fresh,  preferably  raw,  cream  and  milk,  eggs,  beef  juice,  scraped 
beef  or  mutton,  fruit  juices,  and,  with  older  children  only,  the  fruit 
itself.  Fresh  air  and  sunlight,  with  clothing  proper  for  the  season, 
are  demanded.  Rickety  children  improve  at  the  seashore  or  in  the 
country;  many  of  them  do  better  in  the  mountains.  But  few  can 
have  these  advantages.  The  present  tendency  to  make  more  use  of 
roof-gardens  in  connection  with  hospitals  and  city  homes  has  much 
to  commend  it  in  the  treatment  of  rickets  as  well  as  tuberculosis. 
If  we  paid  more  attention  to  providing  sun  and  air  parlors,  and  free 
ventilation  of  hospitals  and  homes  for  children  all  the  year  around, 
they  would  derive  quite  as  much  benefit  as  to  send  them  for  a  brief 
season  to  seaside  or  country.  Sufficiently  warm  clothing  is  requisite 
to  prevent  chilling  of  the  extremities.  In  England  many  hospital 
wards  and  poor  homes  are  too  cold ;  and  children  are,  besides  being 
poorly  fed,  more  thinly  clad  than  in  this  country,  their  legs  often 
exposed  until  blue  with  cold.     In  this  country  we  go  to  the  other 


CONCERNING  CERTAIN   CONSTITUTIONAL  DISEASES        109 

extreme  as  to  heating  of  hospitals  and  homes,  and  invite  catarrhal 
attacks  upon  the  sHghtest  exposure  to  a  change  of  air.  Cold  sponge 
baths  every  morning,  followed  by  brisk  rubbing  till  reaction  is  es- 
tablished, and  also,  if  not  at  the  same  hour  then  later  in  the  day, 
the  employment  of  systematic  massage,  are  among  the  most  useful 
means  to  invigorate  the  patient,  to  increase  the  resistance  to  cold,  to 
improve  the  muscular  tone  and  the  circulation,  and  hasten  metab- 
olism in  the  tissues. 

Of  the  drugs  used  in  rickets,  cod-liver  oil  stands  first.  The 
question  is  still  disputed  whether  it  acts  as  a  drug  or  as  a  food. 
In  this  disease  certainly  one  would  prefer  the  oil  to  any  extract 
made  from  it.  Phosphorus  was  much  used  for  a  time,  and  is  by 
some  still,  in  doses  of  1-200  to  i-ioo  t.i.d.  It  seems  to  do  some 
good  early  in  the  case,  especially  in  cases  with  tenderness  of  epiphy- 
ses somewhat  resembling  scurvy,  and  in  the  nervous  cases.  Hypo- 
phosphites,  iron  and  arsenic  are  much  in  use  in  rickets  as  in  other 
states  of  "  debility,"  that  is,  lowered  vitality  with  malnutrition.  These 
drugs  may  be  used  singly  or  in  various  combinations,  also  with  cod- 
liver  oil.  The  iron  and  the  arsenic  are  certainly  useful  for  the 
anemia.  The  cod-liver  oil  is  given  as  the  stomach  will  tolerate  it, 
The  hypophosphites,  whether  of  much  therapeutic  value  or  not, 
serve  as  a  vehicle.  In  those  cases  accompanied  with  the  lymphatic 
enlargements  the  iron  in  the  form  of  the  syrup  of  the  iodide  is  use- 
ful. This,  in  combination  with  cod-liver  oil  and  syrup  of  the  lacto- 
phosphate  of  lime,  has  been  a  stock  preparation,  inelegant  but 
efficient,  for  dispensary  use  for  many  years.  The  mechanical  treat- 
ment of  rachitis  will  be  discussed  with  regional  surgery.  (12) 

INFANTILE  SCORBUTUS 

Infantile  Scorbutus  {Scurvy;  Barlow's  Disease;  Scurvy- 
Rickets;  Acute  Hemorrhagic  Rachitis.) — The  fact  that  many  sur- 
geons have  cut  down  upon  scorbutic  bone  under  the  impression 
that  they  were  dealing  with  an  acute  periostitis  or  an  osteomyelitis 
or  even  sarcoma,  emphasizes  the  necessity  of  keeping  a  knowledge 
of  this  disease  before  those  who  essay  to  treat  children  surgically. 
Infantile  scorbutus  is  by  some  considered  not  to  be  identical  with 
scurvy  of  adults.  However,  with  the  "  infantile  "  prefixed  it  makes 
a  satisfactory  name.  It  was  long  confounded  with  rickets,  from 
which  it  is  distinct,  though  often  co-existent,  and  the  synonym 
scurvy-rickets  is  unfortunate.  It  is  called  Barlow's  disease  by  the 
English,  after  Dr.  Barlow  of  the  Great  Ormand  Street  Hospital,  who 
wrote  upon  it.  The  resemblance  in  scurvy  and  rickets  is  in  the  bony 
changes,  in  the  age  at  which  they  occur,  and  in  their  dietetic  origin. 
But  the  hemorrhagic  features  of  scurvy  never  appear  in  rickets,  and 


no  SURGICAL   DISEASES    OF    CHILDREN 

the  special  treatment  so  successful  in  scurvy  has  no  effect  in 
rickets. 

Infantile  scurvy  is  a  constitutional  disorder  produced  by  faulty 
nutrition.  The  great  majority  of  cases  occur  in  the  second  and 
third  half  years  of  life,  though  it  can  occur  earlier  or  later,  most 
often  at  the  eighth  or  ninth  month. 

Etiology. — Scurvy  may  occur  in  a  breast-fed  infant,  but  the 
constant  and  prominent  cause  is  found  in  food  that  is  not  fresh, 
especially  the  proprietary  .foods,  condensed  milk,  and  sterilized  milk. 
It  appears  that  the  disease  results  not  only  because  the  food  is  low 
in  proteid,  fat,  sugar  or  salts  (this  may  or  may  not  be  the  case), 
but  because  it  has  been  cooked,  heated  or  dessicated;  it  lacks  the 
quality  of  freshness;  and  because  its  use  has  been  continued  for 
weeks  or  for  months. 

Morbid  Anatomy. — Hemorrhages  take  place  beneath  the  peri- 
osteum of  the  affected  bones,  and  in  fatal  cases  the  periosteum  of 
the  entire  skeleton  may  be  somewhat  loosened.  The  lesions  are  most 
severe  in  the  legs  and  thighs,  the  bones  of  which  may  be  entirely 
denuded  of  periosteum.  Extravasations  of  blood  may  also  be  found 
between  muscles  and  in  cellular  tissues.  Separation  of  the  epiphy- 
sis from  the  shaft  may  occur,  more  frequently  at  the  lower  end  of 
femur  or  tibia.  The  joints  are  usually  not  affected.  Hemorrhages 
or  small  extravasations  may  be  found  upon  any  of  the  mucous  mem.- 
branes,  beneath  the  pleura,  pericardium,  peritoneum,  or  the  skin, 
or  into  lungs  or  kidneys  and  bone  marrow,  and  there  is  marked 
hemorrhagic  gingivitis.  The  microscopic  bone  alterations  resemble 
those  of  rickets. 

Symptoms  and  Course. — In  a  majority  of  the  cases  the  first 
symptom  to  attract  attention  is  tenderness  of  the  legs  upon  handling, 
though  the  infant  may  have  been  considered  puny  for  some  time 
previously.  This  tenderness  may  be  hard  to  localize,  but,  as  it 
appears  to  be  near  the  joints,  is  apt  to  be  mistaken  for  rheumatism, 
which  is  uncommon  at  this  age.  On  closer  examination  it  may  be 
demonstrated  that  the  tenderness  is  not  in  the  joint  itself.  This 
tenderness  increases,  and  the  babe  dreads  to  be  moved  or  even 
touched,  and  becomes  very  unhappy  and  much  distressed.  The 
gums  are  swollen  and  turgid,  bleeding  readily.  This  condition  may 
continue  for  days  or  weeks,  with  fretfulness,  loss  of  appetite,  weight 
and  color.  Or  the  disease  may  advance  to  greater  severity.  Pseudo- 
paralysis of  the  lower  extremities  appears,  due  to  the  extreme  ten- 
derness, or  sometimes  to  separation  of  an  epiphysis.  This  has  often 
been  mistaken  for  the  paralysis  of  poliomyelitis,  which  has  no  ten- 
derness or  swelling.  The  tenderness  is  greatest  at  lower  ends  of 
femur  or  tibia,  and  extends  along  the  shafts  of  the  bones.  Swellings 
appear  in  the  same  situation,  and  discoloration  of  the  skin  over  the 
swellings,  due  to  the  hemorrhage  beneath.    Swelling  and  tenderness 


CONCERNING  CERTAIN   CONSTITUTIONAL  DISEASES        iii 

may  appear  also  near  the  other  joints  of  lower  or  upper  extremities, 
and  even  the  ilium  or  the  ribs.  The  swelling  about  a  knee  may  be 
so  large  and  discolored  as  to  resemble  a  sarcoma.  But  most  often 
both  limbs  are  affected.  The  discoloration  has  the  appearance  of 
a  bruise,  as  in  hemophilia.  Hemorrhages  beneath  the  skin  give 
some  resemblance  to  purpura.  The  gums  and  mouth  resemble  mer- 
curial stomatitis,  but  with  less  salivation.  The  gums  become  im- 
mensely swollen,  of  a  dark  purple,  and  hemorrhage  takes  place, 
not  only  from  the  gums,  but  from  the  roof  of  the  mouth  or  the 
pharynx.  Hemorrhage  may  also  occur  from  the  nose,  bowels,  kid- 
neys, or  stomach.  Hemorrhage  in  the  orbit  may  cause  protrusion 
of  the  eyeball.  The  child  may  fail  greatly  in  its  general  condition 
or  not  appear  so  badly  off,  excepting  as  to  local  conditions.  Com- 
plications may  end  the  case;  or,  if  untreated,  it  may  die  of  exhaus- 
tion or  heart  failure,  the  course  of  the  disease  in  fatal  cases  averag- 
ing two  to  four  months. 

Diagnosis. — After  this  description  it  hardly  seems  necessary  to 
say  anything  further  upon  diagnosis.  A  mistake  could  scarcely 
occur  if  only  this  disease,  with  its  characteristic  features,  be  borne 
in  mind  and  looked  for. 

Treatment  and  Results. — The  treatment  consists  in  discontinu- 
ing the  food  that  has  been  in  use  and  using  fresh  cow's  milk,  modi- 
fied to  suit  the  babies'  digestion,  and  fed  raw.  If  milk  of  proper 
modification,  but  sterilized  or  pasteurized,  had  been  in  use,  the  heat- 
ing should  be  discontinued.  This  would  result  in  cure  in  time. 
But  it  is  much  better  to  use,  also,  orange  juice,  from  a  few  drachms 
to  a  few  ounces  a  day,  in  divided  doses  between  meals.  The  juice 
of  the  lemon,  lime  or  other  fruit  will  do.  Fresh  raw  beef  juice  is 
useful.  Older  children  can  take,  also,  potato  with  benefit,  and  other 
foods.  This  treatment  shows  remarkable  effects,  and  usually 
promptly.  Mild  cases  show  improvement  in  a  few  days.  j\Iany 
cases,  even  though  severe,  recover  in  a  few  weeks,  unless  there 
are  complications  which  give  trouble  and  cause  delay.  Local  treat- 
ment to  the  affected  limbs  should  be  employed.  Hemorrhages  are 
increased  and  fractures  or  epiphyseal  separations  are  produced  by 
slight  accidental  force,  such  as  ordinary  changing  of  the  clothing. 
The  limbs  should  be  protected  and  kept  at  rest  by  bandaging  them 
to  softly  padded  splints  and  the  patient  laid  upon  a  pillow,  mattress 
or  stretcher,  which  can  be  carried  about  as  necessary  without  dis- 
turbing the  patient. 

It  is  remarkable  how  soon  and  from  what  serious  conditions 
scorbutic  infants  will  recover,  once  the  proper  treatinent  is  insti- 
tuted. The  tenderness,  the  spongy  gums,  the  swellings,  the  extrava- 
sations, even  the  periosteal  and  bone  lesions,  clear  up  in  a  way  that 
seemed  impossible.  The  periosteum  resumes  its  attachment  to  the 
bones;  fractures  and  separated  epiphyses  reunite. 


CHAPTER  IV 

VARIOUS  INFECTIONS  AND  THEIR  EFFECTS,  AND 
NON-INFECTIOUS   GANGRENE 

Tuberculosis  —  Syphilis  —  Sapremia — Septicemia — Pyemia — 
Surgical  Scarlet  Fever — Diphtheria  and  Pseudodiph- 
THERiA — Erysipelas — Cellulitis — Acute  Diffuse  Celluli- 
tis— Tetanus  or  Lockjaw — Other  Infections — Acti- 
nomycosis— Gangrene^  Infectious  and  Non-Infectious. 

TUBERCULOSIS 

There  is  abundance  of  evidence,  both  statistical  and  clinical, 
in  the  hands  of  every  practitioner,  to  prove  that  tuberculosis  is  very 
prevalent  in  the  early  years  of  life ;  and,  although  the  present  wide- 
spread organized  and  scientifically  conducted  effort  to  stop  its  rav- 
ages will  lessen  to  a  marked  degree  the  number  of  cases  and  the 
percentage  of  deaths,  it  is  not  probable  that  the  disease  can,  as  the 
sanguine  hope,  be  entirely  banished  from  the  earth.  At  the  best, 
we  in  the  present  generation  will  be  obliged  to  deal  with  it  clinically^ 
as  well  as  prophylactically. 

Heredity. — Modern  investigation  has  almost  laid  the  ghost  of 
heredity,  which  pointed  to  the  early  doom  of  all  whose  ancestors 
were  tuberculous ;  but  has  given  very  alarming  warning  against 
the  danger  of  infection.  It  is  now  held  that  cases  of  direct 
hereditary  transmission  of  tuberculosis  from  parents  to  offspring 
are  exceedingly  rare.  That  infection  of  the  fetus  in  utero  can  pos- 
sibly occur  is  proven  (Schmorl  and  Birch-Hirschfeld),  but  the  fact 
that  Virchow  never  met  with  a  case  of  congenital  tuberculosis  indi- 
cates its  rarity.  In  such  cases  as  are  on  record  of  tuberculosis  being 
transmitted,  or  of  its  being  present  at  birth,  it  is  believed,  upon 
clinical  and  experimental  evidence,  that  the  infection  came  from 
the  mother.  The  father  may  have  tuberculosis,  even  that  of  the 
genital  organs,  with  bacilli  in  the  seminal  fluid,  and  not  transmit 
the  disease.  It  is  undeniable  that  tuberculosis  in  the  family  greatly 
increases  the  chances  of  house  or  contact  infection  of  the  child. 

Diathesis. — It  remains  uncontroverted  that  the  parents,  or 
either  of  them,  may  transmit  a  constitution  peculiarly  vulnerable 
to  tuberculosis — the  "  tubercular  diathesis,"  as  it  is  sometimes 
called.  This  inherent  diminished  power  of  resistance  to  the  inva- 
sion of  the  tubercle  bacillus  and,  perhaps,  of  other  germs  was  for- 


VARIOUS    INFECTIONS    AND    THEIR    EFFECTS  113 

merly  called  "  scrofula,"  and  is  sometimes  still  called  "  struma," 
or  the  strumous  constitution.  Our  predecessors  included  in  struma 
many  conditions  which  we  now  regard  as  incipient,  or  quiescent,  or 
local,  tuberculosis,  such  as  enlarged  lymph  nodes  and  chronically 
inflamed  joints,  cold  abscess  and  dactylitis,  besides  the  tendency  to 
catarrhs  and  pyogenic  infections  of  the  mucous  linings  of  the  upper 
air  passages  and  the  skin  and  adjacent  lymphatics.  With  the  closer 
study  following  the  discovery  of  the  bacillus  of  tuberculosis,  came 
the  suggestion  to  discontinue  the  use  of  the  term  "  struma."  How- 
ever, it  has  been  retained  as  useful,  but  with  its  meaning  limited  to 
be  a  diathesis,  rather  than  any  disease  per  se,  or  to  include  only 
certain  mild  manifestations.  Independent  of  any  marked  diathesis, 
the  resistance  to  infection  varies  greatly  in  all  individuals. 

Predisposing  Causes. — Resistance  may  be  lowered,  and  tissues 
locally  rendered  more  favorable  to  the  reception  or  the  activity  of 
the  infection  by  various  diseases  which  are  very  common  in  infancy 
and  childhood ;  notably  by  measles,  whooping-cough,  chronic  inflam- 
mations of  the  naso-pharynx  and  the  ear,  of  the  bronchi  and  lungs, 
of  the  gastro-intestinal  tract,  and  the  lymphatic  glands.  These  tis- 
sues very  often  furnish  the  infection  atrium.  Any  debilitating 
disease  may  be  a  general,  and  any  local  lesion  a  local,  predisposing 
cause  of  tuberculosis.  Lack  of  nourishing  food,  of  fresh  air,  or 
of  sunlight  predisposes  to  this  disease. 

The  Sources  of  Infection  are  sputum  or  other  discharges  con- 
taining the  bacilli,  and  these  are  conveyed  in  the  air  or  in  drink  or 
food.  The  bacilli  being  inspired  or  swallowed,  find  their  way  either 
through  the  lymphatic  system  or  by  lodgment  in  the  lungs  or  by 
absorption  and  conveyance  into  the  blood,  and  produce  their  char- 
acteristic effects. 

Age  of  Incidence  and  Clinical  Manifestations. — The  effects  of 
the  tubercle  bacillus  are  the  same  in  the  child  as  in  the  adult  as  to 
the  deposition  of  tubercle,  the  production  of  toxines,  the  destruction 
of  tissue.  But  the  distribution  of  the  disease  in  the  system,  and, 
consequently,  the  clinical  form  which  it  takes,  vary  widely  from 
those  in  the  adult,  and  vary  at  different  ages  in  the  infant  and  child. 
Tuberculosis  is  rare  under  three  months,  uncommon  under  six 
months,  more  common  in  the  second  six  months,  and  extremely 
prevalent  and  fatal  in  the  second  year  of  life.  Under  two  years 
the  lesions  are  most  frequent  in  the  bronchial  lymph  nodes,  the 
lungs  and  the  meninges ;  after  that  age  the  cervical  and  the  abdomi- 
nal lymph  nodes  and  the  bones  and  joints.  If  you  mention  tuber- 
culosis to  the  physician  accustomed  to  adult  patients,  he  at  once 
thinks  of  pulmonary  phthisis  as  the  most  common  clinical  form 
of  the  disease.  Mention  tuberculosis  to  a  pediatrist  and  his  mind 
runs  on  glandular,  miliary,  meningeal,   diffused,  lung,  bone   and 


114  SURGICAL   DISEASES    OF   CHILDREN 

joint  and  peritoneal  forms  of  the  disease.  Tuberculosis  of  the 
lymphatic  glands,  bones  and  joints  and  meninges  are  more  preva- 
lent in  the  first  ten  years  of  life  than  ever  afterward. 

To  the  manifestations  of  this  disease  in  the  bones  and  joints, 
in  the  pleura,  the  peritoneum,  the  lymphatics,  and  the  skin  I  shall 
devote  some  further  attention  under  appropriate  headings.  It 
should  be  added  to  this  general  consideration  of  the  subject  that 
this  disease  may  be  acute  or  chronic  even  in  a  young  child.  That 
if  it  is  acute  it  is  more  apt  to  be  general  than  in  an  adult,  and  if  at 
first  local,  more  apt  to  become  generalized,  either  spontaneously 
or  after  surgical  interference.  If  the  disease  is  chronic  it  may  be 
either  general  or  local.  But  if  chronic  and  local,  there  exists  that 
same  proneness  to  become  generalized  upon  slight  provocation. 

Surgical  Treatment. — The  characteristic  just  mentioned  has 
led  to  the  interdiction  of  inconsiderate  surgical  interference  in 
tuberculosis,  but  to  the  most  scrupulous  and  careful  thoroughness  of 
operative  work  when  in  the  selected  case  it  is  decided  upon.  The 
surgical  treatment  is  then,  in  "the  main,  much  more  conservative 
than  it  was  among  our  preceptors,  but  in  case  of  interference  it  is 
more  radical. 

General  Treatment. — The  general  treatment  of  tuberculosis  will 
be  considered  under  the  headings  air  and  climate,  sunlight,  exer- 
cise, rest  and  other  hygienic  measures,  diet,  drugs,  tuberculin,  and 
induced  hyperemia. 

Fresh  air  and  climate  are  as  important  tin  the  treatment  of 
tuberculosis  of  bones,  joints,  glands,  or  other  forms  of  the  disease 
amenable  to  surgery  as  in  pulmonary  phthisis.  A  change  from 
indoor  to  outdoor  life,  or  from  vitiated  to  pure  air  will  as  surely 
bring  a  beneficial  result  in  one  class  of  cases  as  in  the  other.  Im- 
provement may  not  be  as  promptly  noted,  for  the  course  of  tuber- 
culosis in  bone  or  joint  or  glands  is  very  chronic,  and  alterations  are 
slow  to  appear.  A  change  to  the  seaside  or  the  mountains  or  to 
the  country  is  beneficial ;  and  yet  one  has  seen  improvement  quite 
as  striking  result  from  placing  bed-ridden,  house-confined  children 
out  of  doors,  or  even  from  removing  window  blinds  and  windows 
and  keeping  them  indoors.  Of  course,  in  northern  climates  extra 
clothing  is  to  be  provided,  so  that  this  open-air  life  can  be  carried 
out  with  comfort  and  safety ;  but  it  is  perfectly  feasible.  There 
would  not  occur  that  languishing  through  the  fall,  winter,  and 
spring  which  one  has  seen  in  some  hospitals  and  homes,  nor  that 
imperative  necessity  for  a  trip  to  the  country  or  the  seaside,  if 
hospitals  and  homes  were  arranged  to  admit  fresh  air  and  sunlight 
all  the  year  round.  There  are  no  contra-indications  for  the  fresh- 
air  treatment ;  not  even  cough.  The  patient  should  never  be  exposed 
to  inclement  weather,  and  should  never  be  without  sujfficient  pro- 


VARIOUS    INFECTIONS    AND    THEIR    EFFECTS  115 

tection  of  clothing  or  bedding  to  be  perfectly  comfortable.  Exer- 
cise and  oil  massage  of  such  limbs  or  parts  as  are  not  placed  at 
rest,  and  baths  also,  are  excellent  measures  for  improvement  of  the 
general  condition  of  all  these  patients,  even  those  confined  to  bed 
with  joint  and  bone  disease.  Exercise  should  not  be  indulged  in 
if  it  raises  fever  temperature.  Massage  in  the  neighborhood  of 
the  diseased  part  is  not  advised. 

Diet  should  be  carefully  watched,  lest  indigestion  be  produced, 
but  all  the  food  that  can  be  assimilated  should  be  administered. 
Milk,  cream,  and  eggs  are  especially  good  articles  of  diet.  Some 
children  take  olive  oil  well.  Some,  who  cannot  take  any  kind  of 
oil  without  disturbance  of  the  digestion,  can  use  bacon  or  fat  beef 
or  mutton,  when  well  masticated  with  bread. 

Drugs. — Cod-liver  oil  is  a  valuable  article — whether  we  class 
it  as  a  food  or  as  a  medicine  does  not  matter.  Creosote  is  a  useful 
drug,  and  may  be  given  in  various  mixtures  or  in  pill  form,  or  in 
the  cod-liver  oil.  Guaiacol  is  useful  and  may  be  taken  dn  the  same 
way,  or  by  inunction  of  an  ointment  containing  guaiacol,  lanolin, 
and  lard.  Arsenic  is  a  tonic  of  great  value,  which  seems  to  rouse 
the  system  to  resistance  to  the  infection.  Iron,  especially  in  the 
form  of  the  syrup  of  liodide,  has  given  great  satisfaction.  The 
hypophosphites  are  recommended  by  most  writers.  I  have  never 
been  as  sure  of  positive  benefit  from  this  drug  as  I  have  from  the 
others  mentioned.  Any  of  them  must  be  persisted  in  for  a  long 
time  to  get  effects. 

Tuberculin,  which  was  so  enthusiastically  tried  by  everybody 
immediately  after  its  discovery,  was  warmly  praised  by  some  and 
as  vigorously  condemned  by  others,  and  later  restricted,  for  the 
most  part,  to  diagnostic  uses.  More  recently  its  use  began  to  be 
resumed  by  a  few  in  a  more  careful  manner  by  giving,  at  intervals 
of  a  week  or  two,  doses  so  small  as  to  cause  no  perceptible  reaction. 
Still  more  recently,  the  action  of  the  opsonins,  in  connection  with 
the  phagocytic  action  of  the  leucocytes,  has  been  discovered ;  and 
it  has  become  possible  to  test  the  capability  of  the  blood  plasma  (or, 
rather,  of  the  opsonins  which  it  contains)  to  prepare  the  bacteria 
for  destruction  by  the  phagocytes.  By  means  of  such  tests  it  is 
practicable  to  ascertain  whether  the  "  opsonic  index  "  of  the  blood 
is  positive  or  negative,  and  to  what  degree ;  dn  other  words,  whether 
jt  is  capable  of  reacting  to  the  inoculation  of  a  bacterial  vaccine, 
In  the  light  of  these  new  facts  it  would  appear  that  the  vmfortunate 
results  in  the  use  of  tuberculin  were  probably  due  to  using  it  when 
the  blood  was  not  in  condition  to  respond  to  it,  and  that  with  pres- 
ent knowledge  of  the  subject,  such  results  could  be  avoided  by  test- 
ing the  blood  before  the  administration  of  the  tuberculin.  If  by 
this   means   it    shall   prove   that   the   remarkably   beneficial   effects 


Ii6  SURGICAL   DISEASES    OF   CHILDREN 

claimed  by  some  can  be  procured  invariably,  tuberculin  will  assume 
a  very  important  place  in  the  treatment  of  tuberculous  bone,  joint, 
and  gland,  or  other  surgical  affections.  In  localized  tuberculosis, 
especially  that  of  the  bones  and  joints,  as  in  other  infections, 
mechanically  induced  hyperemia  by  the  Bier-Klapp  method  has 
been  used,  with  good  results.  It  is  thought  to  act  by  increasing 
local  leucocytosis  and  phagocytosis,  and  so  causing  the  destruction 
of  bacteria,  by  retaining  locally  to  some  degree  the  products  of 
the  metabolism  of  the  bacteria,  which  thus  destroy  themselves,  and 
by  increasing  locally  the  alkalinity  and  the  bactericidal  power  of 
the  blood.  Bier  claims,  also,  that  processes  of  resolution  and  absorp- 
tion and  of  regeneration  are  stimulated  by  the  hyperemia.  (See, 
also.  Section  on  Septicemia.) 

SYPHILIS 

Syphilis  in  infancy  and  childhood  is  either  acquired  or  in- 
herited. 

Acquired  Syphilis  us  much  less  common  of  the  two.  Yet  it 
should  not.  because  of  its  comparative  rarity,  be  overlooked.  It 
may  be  acquired  from  the  mother  in  the  act  of  birth,  or  later ;  or 
by  nursing  a  syphilitic  wet  nurse ;  or  by  kissing,  or  other  accidental 
contact  of  the  infant  with  a  syphilitic  visitor,  relative,  friend,  or 
stranger ;  or  through  the  medium  of  a  nursing  bottle,  toy  or  the  like ; 
or  by  ritual  circumcision;  or  by  vaccination.  I  have  never  seen  a 
case  acquired  in  these  two  last  mentioned  ways ;  probably  because 
that  part  in  the  original  rite  of  circumcision  requiring  the  priest  to 
put  his  mouth  to  the  wound  is  seldom  now  employed.  The  act  sub- 
stituted for  it.  that  of  squirting  a  mouthful  of  vinegar  or  wine  upon 
the  wound,  leaves  still  room  for  improvement.  A'accino-syphilis 
must  be  practically  unknown  since  carefully  prepared  bovine  virus 
is  used,  and  in  this  country  is  almost  invariably  applied  by  physi- 
cians. Formerly,  when  the  arm-to-arm  method  or  dried  scabs  were 
used,  and  that  often  by  the  laity,  there  is  no  doubt  syphilis  occa- 
sionally occurred,  along  Avith  other  infections,  and  gave  argument 
which  anti-vaccination  erratics  still  employ  upon  the  ignorant.  Svph- 
ilis  is  not  always  acquired  in  ways  so  innocent.  Numerous  cases  are 
on  record  of  syphilis  in  precocious  children  under  ten  years  of 
age,  acquired  by  intentional  contact  with  the  opposite  sex.  Also 
by  contact  with  vicious  nurse-maids,  servants  or  others.  Acquired 
syphilis  presents  the  same  symptoms  in  the  infant  and  child  as  in 
the  adult,  but  runs  a  more  acute  and  severe  course,  and  more  often 
terminates  fatally  than  in  the  adult. 

Hereditary  Syphilis,  the  more  common  form  in  the  young, 
has  received  an  immense  amount  of  study,  and  many  facts  about 
it  are  established,  while  some  questions  are  still  unsettled.     Syphilis 


VARIOUS   INFECTIONS   AND   THEIR   EFFECTS  117 

is  more  often  transmitted  by  the  father  to  the  ovum  by  or  simulta- 
neously with  the  spermatozoon.  The  mother  may  transmit  the 
disease  if  she  is  syphilitic  before  she  becomes  pregnant;  or  if  she 
become  infected  during  pregnancy  and  the  maternal  and  fetal  pla- 
centa be  involved.  If  the  child  was  infected  by  transmission  from 
the  father  it  cannot  infect  its  own  mother,  because  she  became 
immune  during  the  pregnancy.  ("  Colle's  law,"  to  which,  however, 
there  are  exceptions.)  If  both  parents  are  syphilitic,  the  disease 
can  be  transmitted  by  only  one  parent,  because  the  previously 
infected  germinal  cell  is  immune  against  a  second  infection.  The 
more  recent  the  infection  of  the  parents  the  more  prompt  and  the 
more  severe  .will  be  the  syphilitic  manifestations  in  the  child.  Yet 
it  is  possible  for  parents  who  have  recently  had  syphilis  to  produce 
a  healthy  child,  because  the  infection  is  facultative,  and  it  might 
occur  that  neither  the  spermatozoon  nor  the  ovum  contained  the 
syphilitic  poison.  Thus  a  series  of  syphilitic  children  may  be  inter- 
rupted by  an  apparently  healthy  child.  Ordinarily,  a  series  of  chil- 
dren of  syphilitic  parentage  receive  the  infection  in  a  decreasing 
virulence,  as  the  virulence  subsides  with  time  in  the  parent.  There 
are  often  first  one  or  more  abortions,  then  a  premature  birth,  then 
the  birth  of  a  dead  infant  with  severe  lesions,  then  an  infant  born 
alive,  but  surviving  only  a  short  time ;  then  one  with  milder  and  less 
promptly  appearing  lues,  and,  finally,  apparently  healthy  children. 
Such  a  history  is  by  no  means  invariably  obtained,  as  the  disease 
may  have  been  at  a  later  stage  in  the  parent,  or  treatment  may 
have  modified  its  virulence. 

Symptoms. — The  infant  may  be  born  dead.  It  may  be  alive, 
but  a  shriveled,  wrinkled,  mummified  manikin,  with  a  rasping 
squeak  for  a  voice,  and  perhaps  with  bullae  containing  discolored 
serous  fluid  upon  its  muddy-looking  skin,  especially  that  of  the 
palms  and  soles  of  its  scrawny  legs  and  arms.  Its  nails  are  mis- 
shapen, friable  or  claw-like.  It  is  pitifully  weak,  and  subnormal  in 
temperature.  Or  it  may  be  as  plump  and  smooth-skinned  as  a 
healthy  babe.  Lesions  or  other  symptoms  may  not  appear  for  days, 
or  even  months,  generally  not  more  than  two  months,  after 
birth,  and  then  may  first  manifest  the  disease  by  an  un- 
accountable sleeplessness  at  night,  probably  due  to  persistent 
pains ;  or  by  a  progressive  emaciation  without  evident  cause. 
But  in  most  cases  the  first  symptom  is  "  snuffles."  This  is  an 
inflammation  of  the  Schneiderian  membranes,  dry  at  first,  but  soon 
discharging  muco-pus,  sometimes  bloody,  which  excoriates  and 
encrusts  the  nostrils  and  upper  lip.  This  inflammation  is  often  the 
earliest  and  the  most  persistent  symptom.  A  roseolous  eruption  is 
one  of  the  early  signs,  and  this  is  most  marked  where  there  is  most 
moisture  and  irritation,  namely,  about  the  buttocks  and  genitals. 


ii8  SURGICAL  DISEASES   OF   CHILDREN 

where  it  may  become  inflamed  and  excoriated.  But  it  does  not  stop 
at  the  margins  of  the  wet  diaper.  Pemphigus,  or  bullous  syphilide, 
before  referred  to  as  sometimes  present  at  birth,  may  not  show  for 
some  days  afterward.  The  lesions  are  pea-  or  cherry-sized,  and  oc- 
cur most  on  the  palms  and  soles — less  thickly  on  the  extremities,  yet 
more  here  than  on  the  body.  The  babe  may  show  fissures  radiating 
from  mouth  or  anus,  which,  on  healing,  leave  permanent  scars. 
The  skin  eruption  may  be  macular,  with  small  dark  red  or  copper- 
colored  spots  upon  the  palms  and  soles  and  all  over  the  body.  Later 
in  the  case,  papules,  or  a  scaling  of  the  skin,  or  pustules  rarely, 
may  appear.  Mucous  tubercles  or  condylomata  may  come  at  the 
perineum  and  groins,  at  the  flexures  of  the  limbs  or  neck,  or  at  the 
corners  of  the  mouth  or  eyes.  They  may  appear  in  the  mouth  or 
throat ;  or  in  the  larynx,  producing  hoarseness.  Occasionally  there 
is  deafness,  or,  about  the  fifth  month,  iritis  or  choroiditis ;  and  fre- 
quently at  some  period,  stomatitis.  Syphilitic  osteo-chondritis  (also 
called  -chondrosis  and  -peri-chondrosis)  is  an  important  symptom. 
It  affects  the  epiphyses  of  the  long  bones,  chiefly  the  femur,  tibia, 
humerus,  and  also  the  clavicle,  sternum,  and  ribs.  There  is  a  ring- 
like smooth  swelling  around  the  bone  at  the  situation  of  the  carti- 
lage. Sometimes  there  lis  a  sudden  loss  of  function  so  complete  as 
to  resemble  paralysis.  The  trouble  is  apt  to  be  symmetrical,  but  may 
affect  but  a  single  bone.  At  times  there  is  no  other  symptom  to  be 
found.  There  is  more  tenderness  than  in  rickets.  In  a  very  few 
cases  the  osteo-chrondritis  may  cause  separation  of  the  epiphysis. 
Enlargement  of  the  spleen  and  liver  are  found  in  perhaps  half  the 
cases  of  hereditary  syphilis.  Cranio-tabes — soft  spots  in  the  occipi- 
tal and  parietal  bones,  similar  to  that  described  with  rickets,  or  a 
more  general  thinning  of  these  bones — are  found,  and  by  some 
ascribed  to  the  syphilis,  rather  than  to  rickets.  The  condition  occurs 
in  both  diseases,  and  also  occasionally  in  infants,  in  which  other  evi- 
dence of  either  of  these  diseases  is  wanting.  (13) 

About  the  period  of  the  second  dentition,  or  sometimes  not 
until  puberty,  the  patient  develops  the  late  manifestations,  syphilis 
hereditaria  tarda.  Occasionally  there  have  been  no  evidences  of 
lues  in  infancy,  and  the  question  lis  raised  whether  the  case  is  one 
of  hereditary  or  of  acquired  syphilis.  The  symptoms  now  appear- 
ing correspond  to  the  tertiary  stage  of  acquired  syphilis  as  the 
earlier  symptoms  did  to  the  secondaries ;  now,  also,  may  appear 
serpiginous  eruptions,  ulcerations  of  the  nose,  throat  and  hard  pal- 
ate (Figs.  27  and  28),  gummata,  nodes,  visceral  disease,  certain 
nervous  disorders,  meningo-encephalitis,  cerebral  arteritis,  deafness, 
periostitis  and  ostitis,  sometimes  necrosis  and  caries,  and  the 
"  notched  and  pegged  teeth  "  described  by  Hutchinson.  Some  of 
these  symptoms  will  be  described  more  in  detail  here,  while  those 


VARIOUS    INFECTIONS    AND   THEIR   EFFECTS 


119 


pertaining  to  the  lymph  glands,  and  periosteum,  bone  and  cartilage 
will  receive  attention  in  the  chapters  devoted  to  those  subjects. 

Interstitial  keratitis,  a  characteristic  symptom,  is  a  chronic 
inflammation  in  which  a  spot  upon  the  cornea  takes  the  appearance 
of  ground  glass,  and  this,  spreading,  produces  an  opacity,  some- 
times, though  rarely,  accompanied  with  an  inflammation  of  the  iris, 


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Figs.  27  and  28.  Hereuitaky  syphilis.  Destruction  of  nasal  cartilages  and 
bones,  a  late  manifestation.  Scars  at  the  angles  of  the  mouth,  and  near 
eye,  resulting  from  ulcerations.     Boy  aged  9  years. 

resulting  in  adhesions  that  remain  and  distort  the  pupil  even  after 
treatment  has  controlled  the  inflammatory  process  and  cleared  up 
the  cornea.  There  may  be  several  spots  or  flecks  instead  of  only 
one,  and  the  condition  may  affect  one  or  both  eyes.  (Fig.  29.) 
The  middle  ear  often  suffers  a  low,  but  long-continued  inflamma- 
tion, and  the  internal  ear,  also,  is  involved,  with  resulting  auditory 
nerve  atrophy  and  incurable  deafness  affecting  both  sides. 

Diagnosis  in  a  marked  case  of  hereditary  syphilis  is  very  easy, 
but  in  other  cases  it  may  be  very  difficult.  Snuffles  may  readily 
be  considered  an  ordinary  coryza.  But  the  ordinary  coryza  usually 
has  some  other  symptoms  of  a  cold,  such  as  laryngeal  or  bronchial 
catarrh,  and  perhaps  fever,  and  it  does  not  persist  and  become 
chronic  in  the  infant  like  syphilitic  coryza.  There  may  be  congeni- 
tal hypertrophy  of  the  nasal  mucous  membrane,  but  other  symp- 
toms of  lues  are  absent.  Luetic  rashes,  though  red  at  first  appear- 
ance, change  to  the  characteristic  brownish-red  or  copper  color  after 


120 


SURGICAL   DISEASES    OF    CHILDREN 


a  few  days.  A  syphilitic  rash  shows,  also,  elsewhere  than  upon  but- 
tocks and  genitals,  where  irritation  may  have  increased  it.  Pem- 
phigus vulgaris  does  not  involve  the  palms  and  soles  as  syphilitic 
pemphigus  does.  In  the  former,  snuffles  would  be  absent,  also  the 
enlargement  of  the  liver  and  spleen,  the  dirty-colored  skin.  The 
thin  transparent  shining  skin  of  the  palms  and  soles  of  the  atrophic 

or  premature  infant  need 
not  be  mistaken  for  the 
thick,  diffuse  infiltration 
and  desquamation  of  the 
specific  case.  (14) 

The  teeth  which  Jona- 
than Hutchinson  first  de- 
scribed as  the  test  teeth  for 
hereditary  syphilis  are  the 
two  central  incisors  of  the 
permanent  set.  When  typi- 
cal they  slant  toward  each 
other,  though  it  may  be 
otherwise,  and  are  often 
irregularly  placed.  They 
may  be  discolored  from  lack 
of  enamel,  and  each  has  in 
its  edge  a  broad  notch.  (See 
Figs.  22  and  30.)  The 
lower  teeth  may  be  peg-like, 
or  incisors  notched,  and 
either  the  test  teeth  them- 
selves or  others  may  be  ir- 
regularly shaped  or  dwarfed. 
The  teeth  are  usually  some- 
what pointed — that  is,  nar- 
rower at  the  cutting  edge 
than  next  to  the  gum — and 
frequently  the  enamel  is  ir- 
regularly deposited  and  of 
poor  color  and  quality.  Erosions  of  teeth,  discoloration  of  teeth, 
irregular  placing,  or  early  decay  are  none  of  them,  singly  or  all 
together,  evidence  of  luetic  taint ;  nor  is  the  absence  of  the  Hutchin- 
son teeth  proof  of  freedom  from  it.  These  three  symptoms,  diffuse 
interstitial  keratitis,  labarynthine  disease,  evidenced  usually  by  deaf- 
ness without  otorrhea,  and  the  typically  marked  teeth  are  called 
Hutchinson's  triad. 

The  Diagnosis  of  Syphilis  from  the  Blood. — Syphilis  may  be 
diagnosed  from  the  blood  of  a  patient  afflicted  with  this  disease 
by  means  of  a  test  known  as  the  serum  reaction  for  syphilis  (Was- 
sermann). 


Fig.  29.  Hereditary  syphilis,  M.  M. 
Female  aged  75  years,  born  at  7 
months.  Facies  of  hereditary  lues. 
Large  square  forehead  from  bosses 
on  the  frontal  bones.  Low  bridge  of 
nose.  Too  mature  in  expression.  In- 
terstitial keratitis.  (Upper  incisors  of 
temporary  set  not  yet  replaced  by 
permanent  teeth.)  Lost  her  sight  and 
partially  lost  her  mind  between  her 
I2th  and  14th  years.  Afterward  be- 
came insane  and  died  of  obscure  brain 
disease  in  her  17th  year. 


VARIOUS   INFECTIONS   AND   THEIR   EFFECTS  121 

The  principle  of  this  reaction  depends  on  the  fact  that  there 
are  substances  in  the  blood  of  syphilitics  not  contained  in  the  blood 
of  non-syphilitics,  which  have  a  strong  affinity  for  substances  con- 
tained in  extracts  made  from  syphilitic  or  normal  organs,  as  liver. 

When  the  serum  and 
extract  are  brought  to- 
gether in  a  test  tube 
they  unite  and  take  up 
another  substance 
known  as  complement, 
which  is  contained  in  all 
fresh  blood  serum.  As 
this,  however,  is  unat- 
tended by  any .  physical 
change  in  the  mixture 
of  serum  and  extract, 
the  union  could  not  be 
recognized.  There  is, 
however,  a  certain 
method  adopted  to 
demonstrate  that  this 
union  has  taken  place  as 
follows : 

It  is  found  that  if 
you  inject  animal  A,  for 
example,  with  blood  cor- 
puscles of  animal  B,  ani- 
mal A  will  react  against 
the  injected  blood  cor- 
puscles by  producing  an 
anti-body  known  as 
hemolysin,  which  will 
dissolve   the   corpuscles 


Fig. 


30.       Hutchinson     teeth.       Complete 
family  history  of   syphilis. 


It  will  be  found  that  if  you  now  mix  the  blood  serum  of  A  with 
the  corpuscles  of  B  in  a  test  tube,  the  latter  will  be  dissolved.  This 
depends  on  two  factors : 

First. — The  serum  of  A  contains  an  anti-body,  or  ambo- 
ceptor. 

Second. — Complement,  which  is  present  in  all  fresh  sera. 

The  amboceptor  has  an  affinity  on  the  one  hand  for  corpus- 
cles of  B  and  on  the  other  for  complement.  When  this  union 
occurs  the  solution  of  B's  corpuscles  follows.  The  complement 
contained  in  A  or  any  other  serum  can  be  destroyed  by  heating  it 
for  one-half  hour  at  56  degrees  C.  This  leaves  only  amboceptor 
behind  in  the  case  of  serum  A,  which  alone  will  not  dissolve  the 
corpuscles,  consequently  the  mixture  of  corpuscles  and  serum  will 
remain  turbid.     This  is  called  an  inactivated  hemolytic  serum.     If, 


122  SURGICAL   DISEASES    OF    CHILDREN 

however,  you  add  any  fresh  serum,  which  will,  of  course,  furnish 
complement,  solution  will  occur.  Destroying  the  complement  means 
inactivating  the  serum.  To  demonstrate  in  the  first  instance  that 
syphilitic  serum  and  liver  extract  unite  and  take  up  complement, 
both  serum  and  liver  extract  are  inactivated  before  bringing  them 
together  in  a  test  tube.  Some  fresh  serum  (guinea  pig  serum,  for 
example)  is  now  added,  and  the  mixture  allowed  to  incubate  for 
one  hour.  If  the  suspected  serum  was  from  a  syphilitic  patient,  the 
substances  in  the  extract,  the  suspected  serum,  and  the  added  com- 
plement will  unite.  That  this  has  taken  place  can  now  be  demon- 
strated by  adding  the  above  inactivated  hemolytic  serum.  It  will 
be  found  that  the  mixture  will  remain  turbid  because  the  blood 
corpuscles  remain  undissolved,  as  the  complement  necessary  to  the 
solution  was  taken  up  by  the  union  of  extract  and  dnactivated  syph- 
ilitic serum.  If  the  suspected  serum  was  not  from  a  patient  having 
syphilis,  the  complement  will  have  remained  free  and  will  be  taken 
up  by  the  inactivated  hemolytic  serum,  causing  solution  of  the 
corpuscles  and  making  a  clear  transparent  red  fluid. 

The  substances  necessary  in  performing  the  reaction  are  as 
follows : 

1.  Organ  extract. 

Take  part  of  the  liver  of  a  dead  syphilitic  new-born,  place  in 
mortar  with  some  sterilized  sand.  Grind  thoroughly.  For  each 
gram  of  liver  used,  add  five  c.  c.  of  alcohol  (95%).  Pour  mix- 
ture into  sterile  flask.  Heat  in  water  bath  for  one  hour  at  60  degrees 
C.  Filter  into  sterile  bottle.  Keep  at  room  temperature,  ready 
for  use. 

2.  Blood  serum  of  suspected  patient. 

Draw  two  or  three  c.  c.  of  blood  from  a  finger  or  vein. 

Allow  the  serum  to  separate.  Remove  it  by  a  pipette.  If  not 
clear,  centrifugate,  and  the  supernatant  serum  is  removed  and 
inactivated  at  56  degrees  C.  for  one-half  hour. 

3.  Complement. 

Guinea  pig  serum  is  used.  Secure  blood  from  the  animal's 
heart  by  a  hypodermic  needle.  Allow  it  to  coagulate  and  collect 
separated  serum. 

4.  Hemolytic  amboceptor. 

Inject  into  the  vein  of  a  rabbit,  once  a  week  for  three  or  four 
weeks,  five  c.  c.  of  a  5  per  cent,  suspension  of  sheep's  blood  cor- 
puscles. 

One  week  after  the  last  injection,  bleed  the  animal,  allow  serum 
to  separate,  remove,  and  (inactivate  at  56  degrees  C.  for  one-half 
hour. 

5.  Blood  corpuscles. 

Sheep's  blood  is  obtained  from  the  carotid  of  a  sheep,  defi- 


VARIOUS    INFECTIONS    AND    THEIR    EFFECTS  123 

brinated  and  washed  with  salt  solution  three  times,  the  solution 
being  removed  after  each  washing  by  a  pipette.  Enough  salt  solu- 
tion is  then  added  to  make  a  50  per  cent,  suspension  of  blood 
corpuscles.  All  material,  except  organ  extract,  when  not  in  use, 
should  be  kept  on  ice.  Complement  is  unreliable  after  the  third 
day. 

Performance  of  reaction. 

Before  beginning  the  test,  ten  drops  of  salt  solution  are  added 
to  all  tubes  used. 

Two  test  tubes  are  required  for  each  serum.  To  one  of  these 
one  drop  of  serum  and  one  of  extract  are  added,  and  to  one  only 
a  drop  of  serum.  To  a  control  tube,  two  drops  of  extract,  without 
serum,  are  added.  To  all  tubes  a  drop  of  complement  is  added. 
Shake  tubes  and  place  in  incubator  at  37  degrees  C.  for  one  hour. 
Remove  and  add  one  drop  of  diluted  amboceptor  (twice  the  strength 
of  amboceptor  necessary  to  dissolve  a  drop  of  a  50  per  cent,  mix- 
ture of  sheep's  corpuscles,  with  one  drop  of  complement  in  one- 
half  hour,  is  used),  and  one  drop  of  50  per  cent,  suspension  in  salt 
solution  of  sheep's  corpuscles.  If  in  the  tubes  containing  extract 
and  serum,  solution  of  corpuscles  has  not  occurred,  the  reaction  is 
positive,  and  means  that  the  patient  has  syphilis.  If  complete  solu- 
tion has  occurred  the  reaction  is  negative. 

Several  syphlitic  and  normal  sera  are  used  as  controls  in  each 
test  made. 

This  test  is  specific  for  syphilis,  whether  congenital  or  acquired. 
From  90  to  95  per  cent,  of  patients  with  symptoms  of  syphilis  will 
give  a  positive  reaction.  Over  half  of  the  latent  cases  give  a  posi- 
tive reaction.  In  about  70  to  75  per  cent,  of  the  post  syphilitic 
affections  the  blood  will  show  a  positive  reaction.  It  is  a  valuable 
differential  diagnostic  measure  in  bone  and  joint  lesions  of  uncer- 
tain etiology,  in  ulcerative  lesions  of  unknown  cause,  in  lesions  of 
the  liver,  nervous  system,  etc.  It  is  not,  however,  an  organ  or 
tissue  diagnostic  measure.  It  signifies  when  positive  a  systemic 
infection.  Whether  a  given  local  or  organic  lesion  is  caused  by  the 
syphilitic  infection,  other  clinical  facts  must  decide. 

Prognosis. — Many  of  the  cases  born  with  bullse,  or  with 
visceral  lesions,  or  with  other  severe  lesions,  or  showing  them  soon 
after  birth,  die  early.  The  later  after  birth  the  symptoms  first  show 
the  more  favorable  the  prognosis.  Hereditary  syphilis  is  much 
more  grave  in  its  prognosis  than  the  acquired  disease.  All  babes 
born  with  the  disease  are  lowered  in  their  vitality  and  apt  to  suc- 
cumb to  marasmus,  anemia,  enteritis,  pneumonia,  nephritis,  or  some 
septic  disease.  The  mild  cases,  taken  early  and  treated  with  mer- 
cury ,  respond  as  if  by  magic  and  recover,  at  least  for  the  time,  prob- 
ably to  have  recurrences  a  year  or  several  years  later.    Late  syphilis 


124  SURGICAL   DISEASES    OF   CHILDREN 

generally  does  well  under  treatment,  although  nothing  can  eradi- 
cate the  scars  or  stigmata  or  supply  tissues  that  have  been  de- 
stroyed. 

Treatment. — The  first  consideration  is  for  a  supply  of  heat  and 
nourishment.  The  luetic  infant  is  feeble  in  organic  power  and  sub- 
normal in  temperature.  It  may  nurse  its  own  mother  without  dan- 
ger to  her,  although  she  may  give  no  evidence  of  syphilis.  But  it 
should  not  be  allowed  to  take  the  breast  of  a  healthy  nurse,  even 
though  it  may  show  no  lesion  of  mouth  or  nose.  A  nurse's  milk 
may  be  pumped  and  fed  in  a  bottle.  There  is  some  dispute  as  to  the 
degree  of  contagiousness  of  hereditary  syphilis  in  the  infant,  and 
undoubtedly  the  virulence  of  the  contagion  varies  at  different  times ; 
but  the  danger  is  too  great  to  take  any  chances,  by  nursing,  kissing, 
handling  with  abraded  hands,  or  the  like. 

Drug  treatment  consists  mainly  in  the  use  of  mercury  in  some 
form.  Other  drugs  are  used  to  meet  special  indications  or  as  adju- 
vants. One  of  the  best  forms  of  mercury  for  this  purpose  is  the 
gray  powder,  hyd.  cum  cretse.  An  infant  takes  half  a  grain  a  day 
and  thrives  on  it.  After  a  time  he  may  take  a  grain  twice  a  day.  If 
it  affect  the  bowels  too  much,  a  little  opium  can  be  combined  with 
it,  or  tannic  acid,  or  .tan-albumin  or  bismuth  sub-gallate.  Some  use 
hydrargyrum  protoiodide ;  others  use  calomel.  Some  use  mercurial 
ointment  by  inunction,  smearing  the  skin  in  a  new  place  with  a 
piece  the  size  of  a  bean  once  or  twice  a  day.  For  rapid  effect,  baths 
of  corrosive  sublimate  are  used  once  a  day,  ten  grains  to  a  bath, 
remaining  in  the  bath  five  minutes,  unless  the  skin  is  too  much  exco- 
riated. Still  another  method,  especially  good  when  syphilitic  laryn- 
gitis is  troublesome,  is  to  sublime  the  mercury,  under  a  tent,  in  the 
familiar  method  used  for  diphtheritic  croup.  The  oleate  of  mer- 
cury is  an  effective  form.  Other  methods,  by  mercury-impregnated 
aprons,  pads  or  plasters,  by  hypodermic,  et  cetera,  can  be  used,  but 
are  unnecessary.  Luetic  children  are  usually  very  tolerant  of  mer- 
cury, and  yet  its  effect  should  always  be  watched,  and  at  any  signs 
of  gingivitis  or  stomatitis  it  should  be  discontinued.  Mercurial 
stomatitis  is  not  only  painful  and  troublesome  at  the  time,  but  may 
be  followed  by  bad  effects  upon  the  teeth,  especially  those  that  are 
in  the  formative  process  and  not  yet  erupted.  If  no  signs  of  over- 
dosing appear,  the  mercury  is  to  be  continued  till  the  eruption, 
snuffles  or  other  special  symptoms  disappear,  and  for  about  two 
weeks  afterward.  Time  of  treatment  averages  about  six  weeks. 
Iron,  the  saccharated  carbonate,  in  doses  of  half  a  grain  to  a  grain, 
or  later,  the  syrup  of  the  iodide  of  iron,  two  to  ten  drops  at  a  dose. 
Arsenic  also  is  useful  in  combatting  the  anemia  and  cachexia  which 
is  apt  to  be  present.  (15) 

Local  Treatment. — The  moist  eruptions,  tvibercles  or  condylo- 
mata, should  be  dusted  with  calomel  and  bismuth,  equal  parts,  or 


VARIOUS    INFECTIONS   AND   THEIR   EFFECTS  125 

sometimes  simply  with  boracic  acid  when  mercury  is  being  used 
otherwise.  The  coryza  may  be  treated  by  a  solution  of  silver  nitrate, 
one  to  five  hundred,  or  even  one  to  one  hundred ;  rhagades  and 
other  ulcers  may  be  brushed  with  silver  nitrate  solution  of  two  or 
three  parts  to  the  hundred  of  water.  The  incrustations  about  the 
nose  and  corners  of  the  eyes  should  be  removed  and  the  parts 
smeared  with  ointment  of  the  yellow  oxide  of  mercury. 

In  the  treatment  of  the  late  manifestations,  potassium  or  sodium 
iodide  is  the  main  reliance,  to  which  is  added  mercury.  The  iodide 
may  have  to  be  used  in  very  large  doses  and  continued  a  long  time, 
perhaps  for  months,  before  any  effect  can  be  obtained.  The  iodide 
and  the  mercury  can  be  combined  in  a  solution  by  using  the  latter 
in  the  form  of  the  bichloride.  Some  prefer,  again,  to  use  inunc- 
tions or  gray  powder,  or  the  protoiodide  of  mercury ;  or  to  use  the 
iodide  in  solution,  one  grain  to  the  minim.  This  is  merely  a  matter 
of  convenience ;  the  effects  are  practically  the  same.  The  necessity 
of  tonic  treatment  in  these  cases  should  not  be  overlooked,  as  it 
sometimes  is.  Iron  in  some  form  should  usually  be  given  at  inter- 
vals. The  syrup  of  the  iodide  is  a  very  useful  form.  Some  use 
the  ammonio  citrate,  others  the  tartrate  of  iron  with  potash,  or  the 
albuminate,  or  dialized,  or  other  preparation,  often  in  combination 
with  bitter  tonics  and  stomachics.  The  necessity  of  the  most  nour- 
ishing food  must  be  insisted  upon,  and  the  digestion  well  attended 
to  in  order  to  secure  the  desired  results,  not  only  in  the  general 
condition,  but  in  the  healing  of  lesions. 

Local  treatment  for  the  late  lesions  usually  consists  in  the  appli- 
cation of  ointment  of  iodoform,  or  of  the  yellow  oxide  of  mercury 
or  the  white  precipitate,  or  dilutions  of  citrine  ointment ;  or  solu- 
tions of  silver  nitrate  or  of  argyrol,  five  to  ten  grains  to  the  ounce. 
Some  use  the  ointments  to  skin  and  the  solutions  to  mucous  mem- 
branes, such  as  nares  and  throat  or  mouth,  while  some  prefer  oint- 
ments in  the  nares.  One  generally  uses  solutions  where  secretion 
is  abundant  and  the  surface  not  too  sensitive,  and  ointments  when 
the  parts  are  too  dry,  or  over  sensitive  and  in  need  of  protection. 

SAPREMIA 

By  sapremia  we  understand  a  fever  and  accompanying  morbid 
phenomena  caused  by  the  absorption  into  the  system  of  toxines 
produced  by  putrefaction  of  material  confined  in  contact  with  an 
absorbing  surface.  The  absorbing  tissues  themselves  do  not  undergo 
any  putrefactive  change.  They  merely  absorb.  Children  are  fully 
as  susceptible  as  adults,  if  not  more  so,  to  this  form  of  intoxication, 
and  with  them  the  resulting  symptoms  are  apt  to  go  to  the  ex- 
treme. 

Symptoms. — The  symptoms  often  begin  with  a  chill,  followed 
|)y  fever  of  one,  two  or  three  degrees,  a  dry  tongue,  constipated 


126  SURGICAL   DISEASES    OF   CHILDREN 

bowels,  a  flushed  face,  anorexia,  headache,  drowsiness,  or,  if  the 
case  be  allowed  to  go  on,  delirium,  vomiting,  purging,  and  possi- 
bly coma. 

Treatment. — The  treatment  consists  in  getting  rid  of  the  pent- 
up  poison,  drainage  of  the  wound  or  other  containing  cavity,  thor- 
ough cleansing  and  antiseptic  dressing.  At  the  same  time  the 
bowels  should  be  promptly  emptied  by  calomel,  followed  by  a  saline 
purge.  Other  symptoms  should  be  met  by  appropriate  remedies, 
the  weakness  combatted  by  stimulants,  and  especially  should  the  kid- 
neys and  skin  be  kept  active  by  free  use  of  water.  Ordinarily  the 
trouble  will  subside  in  a  couple  of  days. 

SEPTICEMIA 

The  tissues  of  the  young  human  animal  furnish  a  most  favor- 
able medium  for  the  propagation  of  microbial  organisms,  and  we 
find  them  by  no  means  immune  to  the  germs  of  putrefaction  and 
pus  production.  When  these  germs  become  implanted  and  effect 
their  destructive  changes  in  living  tissues,  resulting  in  the  forma- 
tion of  toxines  and  the  absorption  of  these  into  the  circulation,  we 
have  a  dangerous  condition  to  deal  with.  The  intoxication  may  be 
so  rapid  and  so  profound  that  the  system  succumbs  before  there 
is  any  clinical  evidence  of  pus  formation  or  local  destruction  of 
tissue.  Or  if  the  poison  be  absorbed  in  smaller  doses,  or  be  less 
virulent,  or  the  vital  resistance  of  the  organism  be  greater,  the 
patient  survives,  while  his  tissues  undergo  abscess,  ulceration,  gan- 
grene, in  the  parts  attacked  by  infection.  The  point  at  which  the 
infecting  agent  gained  entrance  is  not  always  known,  or  it  may 
appear  insignificant,  entirely  out  of  proportion  to  the  effects  pro- 
duced. Sometimes,  unfortunately,  it  is  the  operation  wound;  or  a 
compound  fracture,  an  accidental  puncture,  a  burn,  a  cut,  a  scratch, 
or  the  bite  of  a  pet  animal ;  or  the  umbilicus  in  the  new-born.  But 
less  obvious  sources  of  infection  should  not  be  overlooked,  such 
as  the  throat,  mouth,  teeth,  nasal  cavities,  the  middle  ear,  or  an  old 
sinus.  This  process  of  invasion  by  septic  micro-organisms  and 
defense  against  the  invaders  gives  rise  to  various  phenomena,  both 
local  and  general. 

Symptoms. — There  may  first  be  malaise  and  some  fever;  or 
the  trouble  may  commence  with  a  chill,  followed  by  a  degree  of 
prostration,  with  loss  of  appetite,  headache,  and  a  typhoidal  condi- 
tion, but  with  irregular  fluctuations  of  temperature.  The  pulse  i^ 
rapid  and  weak.  Rashes  make  their  appearance  upon  the  skin. 
These  eruptions  may  be  erythematous,  or  petechial,  even  pustular 
or  hemorrhagic.  By  blood  examination  a  marked  leucocytosis,  and 
by  cultures  the  invading  organism  may  be  found.  Diarrhea  and 
enlargement  of  the  spleen  are  common.     Endocarditis  or  pericar- 


VARIOUS    INFECTIONS    AND    THEIR    EFFECTS  127 

ditis,  bronchitis,  or  pneumonia  may  appear.  With  disintegration  of 
the  blood  corpuscles,  jaundice  appears.  If  the  infection  atrium 
was  upon  the  surface,  purplish-red  lines  often  show  the  path  of  the 
poison  along  the  nearest  lymph  channels  or  adjacent  veins.  The 
lymph  channels  lead  to  the  lymph  nodes,  which  become  enlarged 
and  tender.  In  unchecked  cases,  redness,  swelling,  extension  of  a 
brawny  swelling,  purulent  discharges,  and  sloughing  or  gangrene 
complete  the  picture  at  the  wound  site ;  and  prostration,  exhaustive 
sweats  and  diarrhea,  with  delirium  or  coma,  end  the  scene. 

Treatment. — At  first  appearance  of  the  case  an  effort  should 
be  made  to  prevent  further  absorption,  and  to  limit  the  extension  of 
that  already  in  the  system.  If  a  foul  wound  or  abscess  be  already 
present,  opening  and  cleansing  of  the  wound,  the  use  of  a  knife  or 
scissors,  curette  or  cautery,  the  removal  of  sloughs  and  of  all  hope- 
lessly diseased  tissues,  even  of  a  hopelessly  diseased  member,  are  in 
order.  Continuous  immersion  in  or  continuous  irrigation  with  hot 
water  or  hot  antiseptic  solutions,  such  as  bichloride  of  mercury,  i 
to  1000  to  5000,  according  to  the  size  and  situation  of  the  wound. 
Paik  recommends  as  a  local  application,  resorcin,  5  parts;  ichthyol, 
10  parts;  ungt.  hydrarg.,  40  parts,  and  lanolin,  45  parts.  This  I 
have  often  used  with  great  satisfaction,  sometimes  substituting 
iodine  for  the  resorcin,  or  changing  the  proportions  of  the  icliihyol 
and  the  ungt.  hydrarg. 

The  Bier-Klapp  Hyperemia  Treatment. — If  there  is  no  gross 
morbific  material  to  be  first  removed,  one  may  proceed  at  once  to 
aid  nature  in  her  method  of  defense  by  inducing  local  hyperemia, 
according  to  the  method  of  Bier  and  Klapp.  When  a  pathogenic 
organism  gains  access  to  the  tissues,  the  flow  of  blood  to  the  part 
increases,  and  there  takes  place  an  exudation  of  leucocytes  and  of 
serum  into  the  tissues.  If  the  vital  forces  are  reacting  properly  the 
serum  contains  antitoxins  which  neutralize  the  toxic  products  of 
the  bacteria ;  also  opsonins  which  prepare  the  bacteria  for  destruc- 
tion and  absorption  by  the  phagocytes  and  the  leucocytes  and  the 
clearing  away  of  the  wreckage  from  the  battleground.  By  increas- 
ing the  supply  of  blood  to  the  diseased  part  and  causing  further 
exudation  of  serum  and  leucocytes,  we  may  aid  nature  in  this  neces- 
sary congestion,  limiting  the  extension  of  the  noxious  agents,  and 
furnishing  in  greater  abundance  the  means  for  their  destruction, 
and  for  the  neutralizing  of  their  poisons.  If  the  area  attacked  be 
upon  an  extremity  the  object  may  be  accomplished  by  constriction 
above  the  diseased  portion  by  a  rubber  bandage,  or  by  cupping;  if 
it  is  upon  the  trunk,  neck  or  face,  the  cups  are  available.  Sufficient 
and  yet  only  sufficient  constriction  or  suction  should  be  used  to  pro- 
duce a  red  and  warm  swelling.  There  never  should  be  coldness  or 
blueness  of  the  part  constricted  or  cupped.    Neither  pain  nor  numb- 


128  SURGICAL   DISEASES    OF   CHILDREN 

ness  should  be  caused  by  the  treatment.  The  elastic  constrictor 
should  encircle  the  limb  above  the  inflamed  area.  A  cup  should  be 
of  such  size  and  shape  that  its  margins  rest  upon  sound  tissue  out- 
side of  the  active  zone  of  the  disease.  In  neither  method  should 
there  be  enough  manipulation  or  pressure  to  disturb  the  surround- 
ing protecting  wall  of  the  leucocytes.  If  there  is  abscess  it  should 
be  opened  by  a  small  incision.  The  cup,  large  enough  to  surround 
the  inflamed  area  and  rest  upon  sound  tissue,  should  then  be 
applied  and  the  discharge  of  the  pus  aided  by  suction.  If  there 
is  no  abscess  the  cup  is  applied  and  suction  used  for  five  min- 
utes. The  cup  is  removed  and  a  period  of  rest  for  three  minutes 
is  allowed,  permitting  a  portion  of  the  blood  to  escape  into  the 
circulation.  The  suction  is  again  applied  during  five  minutes,  and 
again  there  is  a  rest  period  of  three  minutes ;  and  so  on  for  twenty 
to  forty-five  minutes  daily,  or,  in  severe  cases,  twice  daily.  Thus 
there  is  an  increased  amount  of  blood  supplied  to  the  part,  while 
the  flow  of  blood  from  the  part  is  only  slightly  retarded.  According 
to  Wright,  the  blood  which  returns  into  the  circulation  carries  with 
it  a  vaccine  which  stimulates  the  production  of  antitoxins.  At  the 
end  of  each  treatment  the  part  is  gently  bathed,  and  any  pus,  exu- 
date, slough,  or  detritus  that  ds  loose  may  be  removed,  and  a  simple 
wet  dressing  applied.  In  ordinary  infections,  splints  are  not  used, 
and  the  patient  is  encouraged  to  use  the  part.  If  the  inflammation 
is  seen  early  there  is  no  haste  about  making  an  incision,  as  resolu- 
tion is  expected.  If  the  hyperemia  is  to  be  produced  by  the  con- 
stricting band,  this  is  applied  just  sufficiently  tight  to  slightly  impede 
the  venous  return,  but  not  to  interfere  with  the  arterial  supply;  is 
never  painful;  never  causes  blueness,  coldness,  or  numbness.  The 
bandage  is  left  on  for  an  hour  to  two  hours,  once  or  twice  daily. 
One  of  the  difficulties  encountered  in  applying  the  Bier  treatment  has 
been  that  of  securing  just  the  right  degree  of  tension  in  the  Esmarch. 
Wilson  (Jour.  A.  M.  A.,  Apr.  4,  1908)  controls  the  pressure  by  the 
use  of  Cook's  modification  of  the  Riva-Rocca  sphygmomanometer. 
He  has  found  that  (in  adults)  a  pressure  of  10  mm.  less  than  the 
systolic  pressure  induces  a  hyperemia  that  fulfills  the  conditions 
defined  by  Bier,  namely,  warmth,  cyanosis  and  enlargement,  and 
not  blanching  nor  coldness  below  the  constriction,  and  no  pain. 

The  effects  of  the  induced  hyperemia  are  relief  from  pain,  and 
an  increase  of  the  vital  resistance  to  the  infection  and  its  effects, 
so  that  the  disease  is  materially  shortened,  rendered  less  severe,  and 
tissues  and  perhaps  the  life  which  otherwise  would  have  gone  to 
destruction  are  preserved.  This  form  of  treatment  is  eminently 
applicable  to  children. 

The  general  treatment  is  very  important.  It  is  altogether  sup- 
porting and  stimulating.    No  "  antifebriles,"  such  as  coal-tar  deriv- 


VARIOUS   INFECTIONS   AND   THEIR   EFFECTS  129 

atives,  nor  aconite,  are  admissible.  But  the  liq.  ammon.  acet., 
more  used  by  our  preceptors  than  nowadays,  promotes  ehmination 
by  skin  and  kidneys,  without  depressing.  The  temperature  should 
be  controlled  by  use  of  sponge  or  tub  baths,  or  wet-sheet  packs. 
Again  I  must  insist  on  the  importance  of  maintaining  the  nutrition 
in  this  as  in  all  exhausting  conditions  of  childhood.  The  intense 
cell  activity,  the  rapidity  of  the  metabolic  processes  characteristic 
of  this  period  of  life,  make  a  constant  supply  of  nutriment  necessary 
or  the  vitality  cannot  be  maintained,  much  less  any  defensive  or 
reparative  process.  Stimulants  are  in  order,  and  first  in  the  class 
stands  alcohol.  It  is  astonishing  what  large  amounts  of  alcoholic 
stimulants  a  child  in  a  bad  septic  condition  can  take  with  benefit, 
and  without  the  slightest  symptom  of  alcoholic  intoxication.  Whisky 
or  brandy,  well  diluted,  are  the  best  forms.  Quinine  is  useful; 
whether  it  acts  as  a  stimulant  or  as  an  antizymotic  I  do  not  know. 
It  can  be  used  by  suppository  if  necessary.  Strychnia  may  be  used. 
Many  recommend  naphthalin  and  other  intestinal  antiseptics,  such 
as  salol.  The  latter  I  am  afraid  to  use  freely  in  children.  Calomel 
in  small  repeated  doses  seems  to  do  the  work.  Bismuth  is  the 
most  useful  remedy  in  the  diarrhea,  and  enough  opium  should  be 
used  to  control  pain. 

Opsonins,  Opsonic  Index,  and  Vaccine  Therapy. — There  are 
certain  protective  substances  present  in  the  blood  serum  which 
show  the  peculiar  property,  when  brought  in  contact  with  bacteria, 
of  so  acting  on  them  as  to  render  them  easily  taken  up  and  digested 
by  polynuclear  leucocytes.  These  substances  are  known  as  opso- 
nins. They  appear  to  be  specific  for  different  organisms.  They 
are  essential  to  phagocytosis,  and  if  they  are  not  present,  the  poly- 
nuclear leucocytes  will  not  exhibit  phagocytic  powers  to  more  than 
a  minimal  extent.  The  opsonins  and  phagocytes  acting  together 
form  a  defense  or  immunity  apparatus  of  the  organism  against 
bacterial  infection.  (16) 

In  conditions  of  health,  the  opsonic  power  of  the  blood,  by 
virtue  of  the  presence  of  opsonins,  is  approximately  the  same  for 
different  individuals.  Under  circumstances  of  bacterial  infection, 
the  opsonins  are  drawn  on  to  a  greater  or  less  extent  in  the  immu- 
nizing effort  of  the  body  against  the  infection,  thus  causing  a  low- 
ering of  the  normal  opsonic  power.  The  cells  of  the  organism, 
however,  react  against  the  bacteria  and  their  products,  resulting 
in  the  production  of  specific  opsonins,  which  may  periodically  raise 
the  opsonic  content  of  the  blood.  The  resulting  depressions  and 
elevations  in  the  opsonic  content  of  the  blood,  which  are  detectable 
by  a  method  described  below,  are  referred  to  as  "  waves  of  immu- 
nity," which  in  turn  constitute  the  variable  degree  of  defense  or 
resistance  offered  against  the  infecting  bacterium  or  bacteria. 


330  SURGICAL   DISEASES    OF    CHILDREN 

The  technique  of  the  method  devised  by  Wright  for  determin- 
ing the  opsonic  power  of  the  blood  for  any  given  organism  is  as 
follows : 

Materials  necessary — 

(i)   Blood  from  the  patient  to  be  examined. 

(2)  Blood  from  the  normal  individuals  who  serve  as  controls. 

(3)  Washed  blood  corpuscles. 

(4)  Bacterial  emulsion. 

(i)  The  bloods  are  obtained  in  glass  capsules,  curved  at  one 
end,  through  which  the  blood  is  collected  from  a  needle-stick  in 
the  end  of  a  finger,  which  has  been  constricted  by  a  small  rubber 
tubing  or  bandage.  The  opposite  end  of  the  capsule  is  now  sealed 
in  a  flame.  After  some  time  the  blood  clots  in  the  capsule,  and  the 
serum  separates,  usually  along  the  side.  When  ready  to  use  the 
capsule  is  cut  with  a  file  at  a  point  removed  from  the  blood,  and 
broken  off.  The  serum  is  now  accessible  to  the  tip  of  a  glass 
pipette. 

(2)  Washed  corpuscles  are  obtained  by  pouring  several  drops 
of  blood  secured  from  the  finger,  in  the  manner  above  described, 
into  a  small  glass  tube,  which  has  been  about  two-thirds  filled  with 
i^%  Citrate  of  Soda  solution.  This  prevents  the  blood  from  clot- 
ting. The  tube  is  inverted  a  few  times,  the  open  end  being  closed 
by  the  finger,  to  mix  it.  It  is  then  placed  in  a  centrifuge,  with  an 
appropriate  balance  consisting  of  a  similar  glass  tube  filled  with 
the  same  quantity  of  fluid.  The  corpuscles  will  be  thrown  down 
after  some  time.  The  supernatant  fluid  is  now  pipetted  off  and 
physiological  salt  solution  is  added  and  mixed  with  the  corpuscles 
as  above.  They  are  again  centrifuged  in  order  to  wash  them  a 
second  time  to  remove  all  traces  of  serum.  The  salt  solution  is 
thereafter  completely  removed,  and  the  corpuscles  are  ready  for 
use. 

(3)  The  emulsion  is  made  from  a  culture  of  the  particular 
organism,  causing  the  infection  for  which  you  wish  to  test  the 
blood.  The  culture  should  preferably  be  young',  not  more  than 
fifteen  or  twenty  hours  old.  In  case  of  tubercle  bacilli  dry  cultures 
are  used.  In  using  moist  cultures,  one  or  several  loopsful  of  the 
growth  are  mixed  in  physiological  salt  solution  thoroughly  by  draw- 
ing in  and  pouring  out  of  a  fine  pipette  for  several  minutes  in 
order  to  break  up  clumps.  It  is  then  placed  in  a  small  tube  ready 
for  use.  An  emulsion  of  tubercle  bacilli  is  made  with  some  diffi- 
culty. The  dried  bacilli  are  first  ground  up  in  an  agate  mortar  for 
half  an  hour,  and  then  a  i^%  solution  is  added  drop  by  drop  until 
a  smooth  milky  mixture  is  made.  This  is  then  placed  in  a  tube 
which  is  sealed  and  the  tube  and  contents  heated  to  60°  for  one 
hour.     This  is  done  to  prevent  contamination.     It  is  usually  neces- 


VARIOUS    INFECTIONS    AND    THEIR    EFFECTS  131 

sary  before  using  it  to  centrifuge  in  order  that  any  clumps  of  bac- 
teria may  be  thrown  down. 

The  three  essentials  necessary  in  performing  the  work  being 
prepared,  take  glass  pipettes  which  are  made  by  heating  pieces  of 
glass  tubing  about  three  inches  long  and  ^  of  an  inch  in  diameter, 
in  the  flame  of  a  blow-pipe,  the  tubing  being  gently  turned  all  the 
while  and  the  flame  directed  on  the  middle  of  the  tubing.  When 
it  reaches  a  red  heat  it  is  pulled  out  to  a  caliber  of  about  5mm.  and 
divided  by  heating  the  drawn-out  tubing  in  the  flame.  The  ends 
are  cut  at  right  angles  to  the  tube  by  a  file  and  broken  off.  A  blue 
line  is  marked  across  the  pipette  by  a  parafin  pencil  about  f  of  an 
inch  from  the  small  end.  On  the  opposite  or  large  end  a  snug- 
fitting  rubber  teat  is  placed  and  an  equal  volume,  as  indicated  by 
the  blue  line,  of  the  washed  corpuscles,  emulsion  and  serum,  is 
drawn  up  into  the  pipette,  allowing  an  air  bubble  between  each. 
They  are  then  mixed  on  a  glass  slide,  in  the  same  manner  as  the 
emulsion  was  mixed,  and  then  finally  drawn  up  into  the  pipette, 
removed  i-|  to  2  inches  from  the  small  end,  which  latter  is  sealed 
in  a  flame.  The  teat  is  removed  and  the  pipette  placed  in  an  incu- 
bator or  opsonizer,  which  is  a  modified  incubator  made  expressly 
for  this  purpose,  for  ten  to  twenty  minutes.  Whatever  time  is  de- 
cided must  be  observed  for  all  sera,  each  being  examined  sepa- 
rately. 

On  bringing  bacterial  products  in  contact  with  the  cells  of 
the  organism,  as  by  hypodermic  injection,  the  cells  react  against 
these  substances,  producing  antibodies  or  opsonins,  which  thus 
raise  the  resistance  as  measured  by  a  rise  in  the  opsonic  index 
against  these  bodies.  The  bacterial  products,  or  killed  bacteria,  are 
termed  vaccines,  and  treatment  with  them  is  known  as  vaccine 
therapy. 

After  removing  from  the  incubator,  the  sealed  tip  is  broken 
off  and  contents  are  again  gently  mixed  on  a  glass  slide,  using  the 
lips  in  place  of  the  teat.  Then  a  drop  is  blown  on  to  one  end  of 
a  glass  slide,  which  has  been  rubbed  with  emery  paper  on  the  con- 
vex side,  the  drop  gently  drawn  toward  the  opposite  end  of  the 
slide  by  a  glass  spreader,  which  is  made  by  breaking  a  glass  slide 
transversely,  after  it  has  been  nicked  by  a  file.  The  broken  surface 
of  one  part  must  have  a  very  slight  concave  edge  to  be  available. 
Either  tip  of  the  broken  end  is  removed  by  filing  and  breaking. 
It  is  sometimes  necessary  to  break  a  dozen  slides  before  securing 
a  desirable  spreader. 

The  smeared  slide  after  drying  is  now  covered  with  a  satu- 
rated solution  of  Hg  CL  and  allowed  to  stand  for  several  minutes 
to  harden  the  specimen.  It  is  then  washed  off  and  stained.  In 
case    of    tubercle    bacilli,    carbol-fuchsin    with    counter    stains    of 


132  SURGICAL   DISEASES    OF    CHILDREN 

meth3^1ene   blue   is   used.     With   other   bacteria,   carbol-thionine   or 
methylene  blue  may  be  used. 

After  staining  and  drying,  the  slide  is  examined  under  the 
microscope.  If  the  spread  was  well  made,  it  will  be  found  that 
the  leucocytes  are  all  along  the  edge  of  the  smear.  The  bacteria 
contained  in  fifty  (50)  polynuclear  leucocytes,  by  which  they  were 
taken  up,  are  counted.  No  discrimination  is  .made  in  selecting  cells 
for  counting,  as  all  polynuclear  leucocytes,  irrespective  of  whether 
they  contain  bacteria  or  not,  are  counted. 

Two  or  three  normals  are  similarly  counted,  an  average  of 
the  latter  are  taken,  which  constitute  the  normal  phagocytic  count. 
The  phagocytic  count  of  each  abnormal  is  divided  by  the  average 
of  the  normals,  and  the  result  is  the  opsonic  index  for  each  ab- 
normal. If  the  result  is  below  i,  which  is  taken  as  the  index  for 
the  average  normal,  the  patient  is  said  to  be  in  a  negative  phase; 
if  above  i,  he  is  said  to  be  in  a  positive  phase. 

It  will  be  remembered  from  the  above  that  the  organism  may 
react  against  an  infectious  agent,  producing  opsonins  which  raise 
the  opsonic  power  of  the  blood  temporarily,  thus  producing  a  posi- 
tive phase,  during  which  the  patient's  resistance,  and  consequently 
his  capacity  to  overcome  the  infection,  is  increased.  These  are 
termed  autoinoculations.  It  is  clearly  evident  if  we  can  raise  the 
opsonic  index,  and  maintain  it  so — that  is,  the  immunity  wave  of 
the  patient — he  will  overcome  his  infection.  This  it  is  possible  to 
do  by  means  of  vaccine  therapy. 

It  is  necessary  first  to  put  through  one  normal  serum.  The 
average  number  of  bactenia  per  cell  in  fifty  (50)  phagocytes  is  cal- 
culated. This  gives  an  exact  estimate  of  the  thickness  of  the  bac- 
terial emulsion.  An  average  of  three  bacteria  per  cell  is  a  good 
working  emulsion.  The  emulsion,  if  too  thick,  may  be  diluted  with 
salt  solution  sufficient  to  give  approximately  this  average. 

Vaccine  consists  of  killed  cultures  of  bacteria,  and  in  the  case 
of  tuberculin  of  the  extract  of  the  ground-up  tubercle  bacilli.  There 
are  two  varieties  of  vaccines ;  namely,  those  prepared  from  a  cul- 
ture of  the  particular  organism  causing  the  infection,  called  homol- 
ogous or  autogenous  vaccines,  and  those  prepared  from  the  same 
organism,  taken  from  stock  cultures.  These  are  called  stock  vaccines. 

While  it  would  be  desirable  to  secure  an  autogenous  vaccine 
in  each  case  for  treatment,  it  has  been  found  that  in  the  majority  of 
infections  a  stock  vaccine  proves  of  excellent  service. 

Vaccines,  with  the  exception  of  tuberculin,  above  referred  to, 
are  prepared  by  making  several  cultures  of  the  organism  concerned, 
preferably  on  a  solid  medium,  and  allowing  it  to  grow  from  eight 
(8)  to  twenty-four  (24)  hours.  Wash  off  the  growth  with  salt 
solution,  about  10  cc,  pouring  it  from  tube  to  tube  until  washing  is 


VARIOUS    INFECTIONS   AND   THEIR   EFFECTS  133 

completed,  pour  into  sterile  test  tube  and  seal.  Shake  for  one-half 
hour  to  break  up  clumps  of  bacteria.  Standardize  as  follows  :  Open 
the  tube  and  drop  a  drop  of  vaccine  on  a  slide.^  Alark  the  pipette 
as  described  above  with  a  blue  line  to  indicate  a  definite  volume. 
After  puncturing  the  finger,  take  one  drop  of  blood  and  one  of  the 
vaccine  emulsion  and  one  or  two  volumes  of  salt  solution  for  dilu- 
tion. Alix  and  spread  a  drop  on  a  slide  and  stain.  Place  under 
the  microscope  and  count  500  red  cells.  In  the  same  field  in  which 
all  the  red  cells  were  counted,  count  all  the  bacteria  and  note  the 
number  of  bacteria  counted  while  counting  500  red  cells.  As  there 
are  5  m.^  red  cells  in  a  mm.  normally,  there  are  5000  m.  in  a  cc. ; 
so  to  determine  the  number  of  bacteria  in  a  cc.  of  vaccine  emulsion, 
use  the  following  equation — 500  cells,  No.  of  bacteria  counted : : 
5000 :X. 

In  this  manner  a  standardized  vaccine  is  obtained,  and  the  dose 
is  measured  by  the  million. 

Various  infections  have  been  treated  successfully  by  vaccine 
therapy,  notably  infections  with  staphylococcus,  gonococcus,  colon 
bacillus,  tubercle  bacillus,  etc. 

The  dose  of  vaccine  of  different  bacteria  varies.  The  particular 
dose  for  the  patient  depends  on  the  response  noted  in  the  immunity 
w^ave  after  inoculation  as  indicated  by  their  index.  It  is  advisable 
to  start  with  a  moderate  dose  at  first,  and  later  increase.  An  initial 
dose  of  50  m.  is  a  safe  dose  with  most  vaccines.  The  exact  dose 
wall  be  determined  by  a  study  of  the  index,  that  being  the  proper 
dose  which  gives  the  best  response  in  raising  the  index  and  main- 
taining it  above  normal  for  the  longest  time,  also  that  which  shows 
a  substantial  clinical  improvement. 

As  the  quantity  of  vaccine  to  be  administered  is  best  deter- 
mined by  the  index,  so,  too,  is  the  time  of  administraion ;  the  dose 
should  be  repeated  before  the  index  sinks  below  i.  As  it  is  not 
always  practical  to  follow  the  index,  vaccines  may  be  used  without 
their  aid.  Under  these  circumstances  they  will  be  best  used,  how- 
ever, by  those  who  have  learned  their  administration  g^uided  by  the 
index. 

In  cases  of  staphylococcus  infections  w-hich  make  up  most  of 
the  acute  superficial  infections,  as  boils,  furunculosis,  carbuncles,  the 
infections  of  fistulse,  open  w^ounds,  etc.,  they  may  be  treated  by  a 
staphylococcus  stock  vaccine.  The  first  dose  should  be  50  to  100  m. 
The  dose  is  repeated  every  third  or  fourth  day,  increasing  with  each 
successive  dose.    It  is  unnecessary  to  go  higher  than  500  m. 

In   gonorrheal   vulvovaginitis,    or   in   gonorrheal    rheumatism, 

1  The  tube  is  now  sealed  and  the  vaccine  heated  to  60°  for  one  hour  in 
a  water  bath. 
-  m.  million. 


134  SURGICAL  DISEASES    OF   CHILDREN 

gonococcus  vaccine  may  be  used  in  25  to  100  m.  doses,  repeated 
every  fifth  or  sixth  day. 

In  cystitis  due  to  colon  bacillus,  the  colon  vaccine  may  be  used 
in  10  to  25  m.  doses  every  fourth  or  fifth  day. 

All  infections  of  a  mixed  type  require  vaccines  of  the  various 
organisms.  Local  tubercular  dnfections  unattended  with  autoinocu- 
lations  are  successfully  treated  by  tuberculin.  This  is  particularly 
true  of  glandular  tuberculosis.  The  vaccine  treatment  in  tubercular 
infections  is  not  attended  with  rapid  results,  and  often  requires 
months  to  accomplish  the  desired  end. 

Certain  points  are  to  be  remembered  in  vaccine  therapy.  The 
blood  rich  in  opsonins  must  reach  the  bacteria,  or  otherwise  they 
will  be  unaffected  by  them.  Hence,  abscesses  under  tension  should 
be  opened,  if  only  to  relieve  the  tension,  so  that  fresh  lymph  loaded 
with  opsonins  may  pour  into  the  cavity,  after  the  tension  being 
released  on  its  walls. 

Necrotic  bone  is  not  removed  by  vaccine,  and  must  be  taken 
out  before  the  vaccine  will  be  effective  in  eradicating  the  infection. 
Large  abscess  cavities,  as  empyema,  should  be  drained,  and  the 
vaccine  treatment  instituted. 

It  would  be  impossible  in  this  brief  section  on  the  subject  to 
cover  the  wide  range  of  application  of  vaccine  therapy,  or  the  con- 
ditions in  detail  essential  to  its  success. 

PYEMIA 

Pyemia  is,  thanks  to  modern  methods  of  dealing  with  wounds 
and  infections,  seldom  seen  nowadays.  It  is  not  at  all  common 
in  children,  their  cases  of  septic  infection  more  often  than  in  the 
adult  terminating  in  recovery,  or  going  on  to  grave  conditions 
other  than  the  formation  of  thromboses  and  production  of  meta- 
static abscesses.  If  pyemia  follows  an  injury,  it  comes  later  than 
the  usual  septicemia. 

Symptoms. — The  symptoms  are  those  of  septicemia,  with  a 
greater  probability  of  an  initial  chill  and  of  repeated  chills,  and  a 
still  more  irregularly  fluctuating  temperature,  and  complications 
according  to  the  point  of  the  infected  thrombi  in  lungs,  hver, 
joints,  heart,  or  elsewhere. 

Prognosis  is  very  grave  indeed. 

Treatment. — The  treatment  is  the  same  as  that  for  septicemia ; 
in  addition,  opening  and  disinfecting  or  extirpating  the  infected 
vessels  in  the  neighborhood  of  the  wound,  sometimes  the  ligature 
of  an  adjacent  vessel,  and  the  opening  and  drainage  of  the  meta- 
static abscesses  wherever  they  can  be  reached. 


VARIOUS   INFECTIONS   AND   THEIR   EFFECTS  135 

SURGICAL  SCARLET  FEVER 

It  has  often  been  observed  by  surgeons  that  wounds,  and  not 
only  wounds,  but  wounded  patients,  are  extremely  susceptible  to 
scarlet  fever.  The  wound  may  be  attacked,  or  with  a  wound  to 
all  appearances  perfectly  aseptic  and  antiseptically  dressed,  the 
patient  may  be  attacked  with  a  fever,  followed  by  a  scarlet  erup- 
tion. There  has  been  many  a  long  argument  as  to  whether  this 
disease  is  scarlet  fever  or  is  some  more  innocent  variety  of  erythema, 
or  "  scarlet  rash,"  safely  designated  as  surgical  scarlatina,  or  some 
other  distinctive  title.  If  the  germ  could  have  been  identified  the 
argument  would  have  been  sooner  closed.  This  disease  can  and 
often  does,  in  the  surgical  patient,  as  in  other  patients,  vary  so 
extremely  in  its  degree  of  severity  and  its  symptoms  as  to  be  very 
obscure.  Surgical  scarlet  fever  can  be  communicated  to  other 
patients,  even  to  adults,  and  those  not  wounded;  it  can  produce 
desquamation  and  albuminuria ;  and  it  is  settled  beyond  a  doubt  upon 
clinical  evidence  alone  that  surgical  scarlatina  is  scarlet  fever,  and 
it  should  be  isolated  and  treated  as  such. 

But  scarlet  fever  may  be  considered  in  another  sense  as  a  surgi- 
cal disease  especially  afflicting  childhood,  and  on  account  of  its 
close  affinity  for  the  pyogenic  organisms  and  erysipelas  often  gives 
rise  to  surgical  complications  and  sequellae.  Common  instances  are 
the  post-scarlatinal  abscesses,  adenopathies  and  arthropathies,  which 
will  be  referred  to  later.  In  case  of  post-scarlatinal  operation,  the 
probability  of  nephritis  and  its  dangers  in  relation  to  anesthesia 
should  be  borne  in  mind. 

DIPHTHERIA    AND    PSEUDODIPHTHERIA 

Diphtheria  is  an  acute  infectious  disease  caused  by  the  Klebs- 
Loeffler  bacillus,  characterized  by  inflammation  with  pseudo-mem- 
branous exudation  upon  any  mucous  membrane,  wound  or  abrasion, 
with  amplication  of  adjacent  glands,  albuminuria,  heart  weakness, 
and  also  with  great  general  prostration,  anemia,  moderate  fever,  and 
other  constitutional  evidences  of  toxemia. 

The  false  membrane  caused  by  the  propagation  of  this  ba- 
cillus grows  upon  and  adheres  to  the  tissues,  usually  not  being 
separable  in  the  early  stages  without  bleeding.  It  varies  from  a 
filmy  mucoid  coating  to  the  thickness  of  paper  or  of  chamois  skin, 
and  in  color  is  white  or  grayish  white,  or  yellowish,  or  brownish, 
or  dirty  gray,  or  blackish.  It  is  composed  of  a  structureless  net- 
work of  fibrin  containing  in  its  meshes  necrotic  epithelium,  pus 
cells,  blood  and  round  cells,  cocci,  diphtheria  bacilli  and  debris. 
The  disease  may  be  found  in  the  throat,  nares,  pharynx,  larynx, 
upon  wounds  or  abrasions,  the  lips  or  buccal  surfaces,  the  palpebral 


136  SURGICAL   DISEASES    OF    CHILDREN 

conjunctiva,  in  the  esophag-us  or  stomach,  upon  eczematous  patches, 
upon  the  glans  penis  or  vulva,  at  the  umbiHcus  or  elsewhere. 

The  bacilli  themselves  do  not  enter  the  blood,  but  during  their 
growth  a  ferment  is  formed  which  is  capable  of  digesting  proteids. 
These  digested  proteids  or  toxalbumins  or  albumoses  when  absorbed 
into  the  blood  act  as  virulent  poisons.  The  ferment  is  also  pres- 
ent in  the  blood  and  is  capable  of  acting  on  the  blood,  producing 
loss  of  hemoglobin  and  decrease  of  erythrocytes,  and  leucocytosis. 
But  the  toxemia  may  be  so  great  as  to  overwhelm  phagocytic  activ- 
ity and  produce  leucopenia;  there  is  cloudy  swelling,  and  some- 
times acute  inflammation  and  degeneration  of  the  kidneys ;  changes 
occur  in  the  liver  with  cell  necrosis  and  hemorrhages.  Degenera- 
tions take  place  in  nerve  tissues  with  multiple  neuritides,  in  periph- 
eral nerves,  and  in  the  spinal,  involving  the  multipolar  cells  of  the 
anterior  columns. 

The  toxemia  produced  by  the  diphtheritic  process  is  in  propor- 
tion to  the  virulence  of  the  infection,  the  extent  of  the  process,  and 
the  capacity  for  absorption  of  the  tissues  where  it  is  located,  as 
well  as  the  resistance  of  the  patient.  The  effects,  general  and 
local,  are  also  influenced  by  the  action  of  symbiotic  organisms, 
which  are  almost  invariably  present  with  the  Klebs-Loeffler  bacillus. 
Among  these  are  the  staphylococcus,  the  pneumococcus,  strepto- 
coccus, and  the  colon  bacillus.  The  results  of  these  mixed  infec- 
tions frequently  produce  adenitis,  cellulitis,  abscess,  not  only  in 
parts  adjacent  to  the  seat  of  the  attack  and  during  the  acute  illness, 
but  they  not  infrequently  produce  septic  and  pyogenic  processes  in 
these  situations  and  more  remote,  as  abscesses  of  bone  or  perios- 
teum, or  in  lungs,  liver,  spleen  or  kidneys,  and  elsewhere,  as  se- 
quellae  of  the  disease. 

Diagnosis. — The  diagnosis  is  made  upon  the  appearance  of  the 
characteristic  adherent  false  membrane  wherever  found,  without 
waiting  for  constitutional  symptoms  or  local  complications  to  super- 
vene. The  microscope  employed  with  proper  technique  reveals  the 
diphtheria  bacillus.  It  is  well  to  remember  that  if  caustics  or  strong 
antiseptics  have  been  used  locally  before  the  swab  was  taken,  the 
characteristic  organism  may  not  be  found.  Also  that  the  presence 
of  the  germ  without  symptoms  local  or  general  does  not  constitute 
the  disease.  And  also  that  diphtheritic  poisoning  can  occur  with- 
out the  appearance  of  the  characteristic  local  lesions.  Furthermore, 
that  there  are  other  organisms  than  the  Klebs-Loeffler  bacillus  ca- 
pable of  producing  false  membranes,  for  instance,  the  pneumo- 
coccus, streptococcus,  staphylococcus,  gonococcus,  bacterium  coli. 

PsEUDODiPHTHERiA. — The  name  diphtheria,  from  the  Greek, 
signifies  leather  or  leathery,  and  was  applied  not  only  to  all  cases 
of   angina,   but  to   all   conditions   presenting   a    leathery    exudate 


VARIOUS    INFECTIONS    AND    THEIR    EFFECTS  137 

upon  the  surface.  Now  the  word  is  restricted  to  the  disease  caused 
by  the  Klebs-Loeffler  bacillus,  and  conditions  accompanied  by  for- 
mation of  false  membrane  or  fibrinous  exudate  are  called  pseudo- 
diphtheria  or  diphtheroid.  There  is,  however,  a  bacterium  closely 
resembling-,  morphologically  and  in  its  staining  qualities,  the  true 
diphtheria  bacillus,  differing  from  the  latter  an  its  toxemic  effects 
and  in  its  sequellae.  It  can  be  differentiated  by  inoculation  experi- 
ments. This  organism  has  been  named  the  pseudo-diphtheria  ba- 
cillus, and  the  disease  which  it  produces  diphtheroid.  It  would  be 
better  if  the  use  of  this  name  were  to  be  restricted  to  this  germ, 
but  at  present  it  is  often  used  to  include  all  the  conditions  clin- 
ically resembling  diphtheria  with  its  false  membrane,  yet  caused 
by  other  organisms  than  the  Klebs-Loeffler,  and  is  even  applied  to 
the  fibrinous  exudates  upon  the  intestinal  and  genito-urinary  tracts 
in  surgical  cases,  although  they  are  usually  caused  by  streptococcus 
or  staphylococcus  infection. 

Prognosis. — The  prognosis  in  diphtheria  depends  upon  the 
stage  at  which  treatment  is  instituted,  and  upon  whether  the  germ 
is  in  pure  culture  or  the  infection  is  a  mixed  one.  Also  much 
depends  upon  the  patient's  general  vigor  and  upon  his  surround- 
ings. The  situation  of  the  local  disease  has  much  to  do  with  the 
probabilities  according  to  the  absorbing  surface  or  to  interference 
with  function.  Greater  toxemia  may  be  expected  in  the  post-nasal 
than  in  the  tonsillar  form,  and  in  either  of  these  than  in  the  laryn- 
geal. In  this  latter  the  greatest  danger  is  from  laryngeal  stenosis. 
(See  Chapter  on  the  Air  Passages.)  In  diphtheritic  wounds  the 
same  rules  apply.  In  conjunctival  cases  the  results  may  be  espe- 
cially disastrous. 

Treatment. — The  treatment  is  by  early  and  vigorous  use  of 
antitoxin,  and  in  mixed  infections,  wound  infections  and  pseudo- 
diphtheria  by  antiseptics  used  on  general  surgical  principles.  Also, 
and  especially  in  true  diphtheria,  in  the  use  of  alcoholic  stimulants 
and  strychnia,  rest  and  forced  nutrition  in  the  best  sanitary  sur- 
roundings. ( See  also  Section  on  Opsonins,  Opsonic  Index  and  Vac- 
cine Therapy.) 

ERYSIPELAS 

Erysipelas  occurs  in  new-born  babies  and  in  older  infants  and 
children.  In  the  new-born  it  is  apt  to  start  at  the  umbilicus  or  a 
circumcision  wound  or  an  abrasion  received  from  obstetric  instru- 
ments. In  older  infants  it  begins  from  any  opening  of  the  skin 
or  mucous  membrane,  often  about  the  genitals  or  anus,  mouth, 
nose,  or  eyes,  but  frequently,  as  in  the  adult,  the  point  of  entrance 
of  the  germ  cannot  be  determined.  The  symptoms  are  the  same 
as  in  older  patients ;  the  same  rose  color  of  the  skin  with  the  inflam- 
matory thickening  following  the  margin  of  the  reddening.     But  in 


138  SURGICAL   DISEASES    OF   CHILDREN 

young  children  it  has  appeared  to  me  to  be  more  rapid  and  wide 
in  its  extension  and  less  regular  in  outline  than  in  the  adult,  and 
the  roseate  color  to  flash  ahead  of  the  infiltration.  The  constitu- 
tional symptoms  are  similar:  high  fever,  great  prostration,  some- 
times chills  or  convulsions,  vomiting,  in  severe  cases  bronchitis  and 
diarrhea. 

Diagnosis. — The  diagnosis  is  not  difficult,  yet  one  has  seen  ex- 
perienced practitioners  fail  to  recognize  it  because  of  irregular 
shape  of  its  margins  or  the  extent  of  the  skin  implicated. 

Prognosis. — The  prognosis  is  bad  in  cases  occurring  in  the 
new-born.  When  beginning  at  the  umbilicus  the  disease  is  apt  to 
extend  to  the  umbilical  veins  and  peritoneum,  and  from  the  veins 
to  produce  metastases.  In  older  infants  and  in  children  one  has  not 
considered  the  prognosis  so  grave,  at  least  in  fairly  strong  patients, 
as  some  writers  assert;  but  have  thought  the  disease  usually  took 
a  milder  course  than  in  the  adult,  and  that  sometimes  the  child 
recovered  from  a  condition  more  extensively  diseased  than  an  adult 
would  have  recovered  from. 

Treatment. — Separation  from  all  surgical  and  obstetrical  pa- 
tients is  imperative,  and  complete  isolation  is  advisable.  Free  ex- 
cretion by  bowels  and  kidneys  should  be  secured.  After  that,  stim- 
ulants are  called  for — quinia,  strychnia,  and  whisky  or  brandy. 
Locally,  the  old-fashioned  lead  lotion  is  still  good,  sometimes  with 
opium.  Powdered  oxide  of  zinc,  lotions  of  saturated  solution  of 
boracic  acid  are  used,  always  covering  the  dressing  with  oil-silk. 
But  of  all  the  remedies,  I  know  of  none  better  than  ichthyol,  lo  to 
25  per  cent.,  in  ointment  with  lanolin,  or  the  same  in  combination 
with  the  unguentum  hydrargyri  and  resorcin,  as  is  highly  recom- 
mended by  Roswell  Park.  Ointment  of  the  iodide  of  mercury  with 
ichthyol  has  controlled  many  streptococcic  inflammations. 

CELLULITIS 

Cellulitis  is  an  inflammation  due  to  infection  by  a  strepto- 
coccus, or  the  pneumococcus,  or  the  bacillus  coli,  or  a  mixed  infec- 
tion, invading  the  cellular  tissues.  It  is  often  called  Ludwig's  an- 
gina, since  described  by  Ludwig,  a  surgeon  of  Stuttgart,  in  1836. 
It  often  accompanies  one  of  the  infectious  fevers  or  some  lowering 
disease,  very  often  scarlet  fever,  diphtheria,  or  pseudodiphtheria. 
It  may  appear  in  various  situations  and  under  various  circum- 
stances, as  with  osteomyelitis,  peritonitis,  or  extending  from 
wounds;  but  the  form  most  frequently  seen  in  children,  and  quite 
typical  of  the  condition,  occurs  in  connection  with  diphtheria,  par- 
ticularly "mixed  infection  diphtheria,"  or  with  scarlet  fever.  The 
lymphatic  glands  at  the  angle  of  the  jaw  become  swollen  and  tender, 
as  is  frequent  in  these  diseases,  but  the  process  does  not  stop  with 


VARIOUS    INFECTIONS   AND   THEIR   EFFECTS  139 

the  glands ;  it  extends  into  the  celhilar  tissues  all  about  them,  caus- 
ing a  brawny,  tense  edema  from  the  jaw  to  the  clavicle,  and  some- 
times involving  both  sides.  The  head  is  held  backward  and  is 
almost  immovable  from  the  thick  inflammatory  mass  in  front. 
Swallowing  is  not  always  more  interfered  with  than  it  was  from 
the  primary  disease.  There  is  always  increased  fever,  often  de- 
lirium, and  later,  in  bad  cases,  prostration  and  coma.  The  swelling 
is  not  discolored  early  in  the  case,  and  it  does  not  run  to  prompt 
suppuration.  In  a  severe  case  the  patient  sinks  from  the  sepsis 
before  there  is  any  external  indication  of  pus  formation.  But  in 
some  of  these  cases  pus  would  be  found  by  going  beneath  the  deep 
fascia. 

Diagnosis. — From  the  ordinary  lymphadenitis  so  common  in 
scarlet  fever  or  throat  infections,  it  is  easily  differentiated  by  its 
extension  outside  of  the  glands,  which  cannot  be  palpated  nor 
moved  about,  glands  and  surrounding  tissues  being  in  one  brawny 
mass. 

Prognosis. — This  disease  was  more  often  seen  when  less  atten- 
tion was  paid  to  antisepsis  in  throat  and  mouth  in  scarlet  fever,  and 
before  the  days  of  diphtheria  antitoxin ;  and  was  especially  dreaded 
before  intubation  was  put  in  practice;  for  in  the  event  of  trache- 
otomy being  indicated  in  a  marked  case  of  cellulitis  involving  the 
whole  front  of  the  throat,  it  was  almost  impossible  to  perform  it, 
or  to  put  a  tracheotomy  tube  in  position.  Moreover,  the  cases  were 
usually  hopeless  even  if  tracheotomized.  Antitoxin  does  not  cure 
septic  cellulitis;  but  since  its  use  few  cases  of  diphtheria  run  to 
such  length,  and  fewer  develop  cellulitis  of  that  severe  type.  It  is 
always  a  serious  condition,  and  often  fatal.  When  less  extensive, 
and  properly  treated,  in  a  patient  not  greatly  debihtated  or  toxemic 
from  the  primary  disease,  recovery  will  follow. 

Treatment. — If  the  Klebs-Loeffler  bacillus  was  suspected  of 
causing  the  primary  disease,  or  of  being  secondary  in  a  case  of 
scarlet  fever,  diphtheria  antitoxin  should  be  given.  I  have  so  far 
never  been  able  to  derive  much  benefit  from  anti-streptococcic  serum. 
The  application  of  ichthyol  and  unguentum  hydrargyri,  sometimes 
with  guiacol,  has  effected  some  good.  When  the  swelling  has  be- 
come tense  and  brawny  it  should  be  incised,  and  this  probably  in 
several  places,  with  due  regard  for  the  large  vessels.  The  incisions 
should  go  below  the  deep  fascia,  and  will  serve  as  a  drain  even  if 
no  pus  is  encountered.  Pus  may  flow  a  day  or  two  later.  Com- 
presses of  bichloride  gauze  serve  as  a  dressing. 

These  cases  demand  all  the  assimilable  nutriment  they  can 
take,  an  abundance  of  water  to  drink,  and  unstinted  use  of  brandy 
or  whisky.  Strychnia  and  heart  tonics  are  generally  needed. 
Baths  and  the  ice  cap  moderate  fever  and  nervous  symptoms  better 


140 


SURGICAL  DISEASES    OF   CHILDREN 


than  drugs.     The  mouth  and  inside  of  the  throat  should  be  kept 
cleansed  with  pleasant  antiseptic  sprays  or  gargles. 

ACUTE   DIFFUSE   CELLULITIS 

It  has  seemed  to  me  that  the  new-born  infant  is  especially 
subject  to  a  form  of  acute  diffuse  cellulitis  or  lymphangitis.  This 
is  either  very  mild  in  its  character  or  else  the  infantile  organism, 
while  a  fertile  soil  for  infections,  has  also  peculiar  resources  for 
combatting  them.  For  with  this,  as  with  some  other  infections 
observed  in  the  very  young,  the  malady  has  pursued  a  peculiar 
course.    This  inflammation  of  the  subcutaneous  cellular  tissues  does 


Fig.  31.  Head  of  infant  with  septic  inflammation  undermining  the 
scalp  and  sloughing  of  the  scalp.  Recovery.  Case  seen  with  Dr.  I.  W. 
Bard. 

not  affect  the  deeper  tissues  to  any  extent,  and  the  skin  is  affected 
apparently  mostly  by  the  extensive  separation  which  takes  place 
between  it  and  the  cellular  tissue  beneath  it,  causing  it  to  break 
down  and  slough  in  patches.  The  inflammation  beginning  at  one 
point  is  apparently  not  surrounded  by  the  usual  exudation  of  fibrin 
and  leucocytes,  at  least  it  is  not  circumscribed,  but  spreads  rapidly 
beneath  the  skin,  thickening  it  and  giving  it  a  tallowy  feeling  to 
the  touch.  The  areolar  attachments  of  the  skin  are  destroyed  ex- 
cepting at  their  strongest  points  of  adherence,  so  that  extensive  skin 
surfaces  floating  upon  a  layer  of  pus  or  lymph  are  tied  down  at 
those  adherent  points,  giving  such  surfaces  a  "  hobnail  "  appear- 
ance, I  have  seen  half  the  back  and  both  shoulders  and  neck  of  an 
infant  in  this  condition. 

Fig.  31  shows  the  head  of  an  infant  in  which  a  purulent  under- 
mining inflammation  of  the  cellular  tissue  under  the  scalp  had  re- 
sulted in  sloughs.  IMeanwhile  there  is  surprisingly  little  constitu- 
tional disturbance,  and  after  a  time  the  infant  recovers  from  what 
would  seem  in  an  older  person  a  quite  extensive  infection.  The 
ordinary  pus  germs  are  believed  to  be  the  causes  so  far  as  dis- 


VARIOUS    INFECTIONS    AND    THEIR    EFFECTS  141 

covered  in  the  purulent  cases.     But  in  those  causing  the  lymph- 
stasis  before  mentioned  no  organism  was  detected. 

Treatment  is  by  evacuation  of  the  pus,  or  lymph,  by  free  open- 
ings at  different  points  to  prevent  burrowing,  and  antiseptic  dress- 
ings. 

TETANUS  OR  LOCKJAW 

Tetanus  or  Lockjaw  is  an  acute  infectious  disease,  caused  by 
the  tetanus  bacillus  of  Nicolaier  (1884)  and  Kitasato  (1889).  The 
bacillus  is  a  strict  anaerobe,  and  abounds  in  the  soil,  more  fre- 
quently, it  is  thought  (Verneuil),  in  soil  mixed  with  horse-manure. 
This  germ  when  cultivated  in  a  suitable  medium  or  introduced  into 
a  wound  in  a  susceptible  animal  has  the  property  of  generating 
certain  virulent  poisons  (tetanin,  tetano-toxin,  spasmo-toxin),  (Brie- 
ger),  which  when  injected  or  absorbed  into  the  system  produce 
peculiar  and  generally  fatal  spasms.  The  bacillus  of  tetanus  has 
the  peculiarity  that  it  is  seldom  found  in  the  tissues  far  away  from 
the  wound  where  it  was  introduced,  although  it  has  been  demon- 
strated in  the  blood  and  in  the  sheaths  of  the  nerves  near  the  wound 
and  extending  toward  the  cord,  and  even  in  the  cord  itself.  But 
it  appears  that  the  toxins  are  generated  at  the  wound,  and  travel 
toward  the  cord  and  medulla  by  way  of  the  nerves.  They  are  found 
in  all  these  structures,  dn  the  cerebro-spinal  fluid,  and  also  in  the 
blood,  being  likewise  transported  by  that  medium.  Another  strange 
quality  is  that,  although  in  the  laboratory  its  period  of  incubation 
is  seldom  longer  than  forty-eight  hours,  it  has  in  some  cases  been 
known  to  produce  its  characteristic  effects  only  after  a  delay  of 
several  (Park  says  eight)  weeks  later  than  the  infection  of  the 
wound. 

Pathology. — The  wound  of  entrance  may  show  moderate  in- 
flammation ;  or  the  inflammator}^  process  may  be  over-past.  The 
inflamed  wounds  are  those  in  which  there  was  a  mixed  infection. 
The  lesions  of  nerves  and  nerve  centers  are  merely  those  resulting 
from  an  irritant  poison.  In  the  cord  the  greatest  change  is  seen  in 
the  cells  of  the  anterior  cornua,  with  hyperemia  of  the  cord  and 
medulla.  Other  appearances  may  be  due  to  the  spasms,  for  in- 
stance, small  and  occasionally  large  hemorrhages  in  the  meninges, 
especially  at  the  base,  or  in  the  brain  itself,  and  congestion  of  the 
lungs  and  dilatation  of  the  heart. 

As  to  distribution,  the  disease  is  endemic  in  some  countries, 
for  instance,  Jamaica,  the  Faroe  Islands,  India,  more  frequently  in 
warm  countries,  being  apparently  more  prevalent  in  our  own 
Southern  States  than  in  the  North.  But  it  is  not  at  all  uncommon 
in  the  Northern  States.  It  seems  to  have  favorite  localities  for 
its  habitat,  the  area  of  one  county  or  township  presenting  more 
cases  than  another.     In  those  countries  where  tetanus  prevails  so 


142  SURGICAL   DISEASES    OF    CHILDREN 

extensively  the  great  majority  of  the  cases  are  in  new-born  infants. 
Military  field-service  in  hot  climates  has  tetanus  especially  to  con- 
tend with.  In  this  part  of  the  world,  while  it  occasionally  occurs 
in  casualty  and  almost  never  at  this  day  in  elective  surgery  upon 
adults,  the  majority  of  the  cases  occur  in  the  new-born  and  in 
children,  frequently  boys,  with  small  wounds  of  the  extremities. 
Lacerated  or  punctured  wounds  seem  to  afford  particularly  favor- 
able conditions  for  this  germ,  and  when  the  wound  is  inflicted  upon 
a  soiled  hand  or  the  foot  of  a  barefoot  child  the  chances  are  great 
for  the  presence  and  the  implantation  of  the  germ.  If  the  wound 
is  so  slight  as  to  receive  no  surgical  attention,  or  if  with  a  punc- 
tured wound  that  surgical  attention  does  not  consist  in  a  thorough 
opening  and  antiseptic  cleansing  of  the  wound,  the  conditions  are 
at  their  best  for  the  propagation  of  this  anaerobe  and  the  produc- 
tion of  its  subtle  and  powerful  poison.  For  these  reasons  it  is  not 
strange  that  so  great  a  percentage  of  the  cases  occur  from  the 
infection  of  the  umbilicus  of  the  new-born  babe  wrapped  tightly  in 
a  dressing  which  is  never  changed,  or  in  the  boy  with  his  fond- 
ness for  the  toy  pistol  that  explodes  a  tiny  bombshell,  projecting 
its  fragments  beneath  his  skin;  or  from  the  puncture  of  a  sole  or 
palm  by  a  nail  or  a  splinter.  Burns  also  have  a  bad  reputation 
for  opening  the  way  for  tetanus. 

Tetanus  has  been  variously  classified,  but  the  disease  by  what- 
ever name  is  always  produced  by  the  same  infecting  agent,  and  is 
always  introduced  by  a  solution  of  continuity;  and  while  placing 
it  under  different  headings  may  serve  to  attract  attention  to  the 
probable  atrium  of  infection  and  certain  modification  of  the  symp- 
toms and  course,  it  should  not  conceal  the  identity  of  the  disease. 
Tetanus  neonatorum  is  of  the  same  nature  as  traumatic  tetanus  or 
"  toy  pistol  tetanus,"  and  idiopathic  tetanus  is  identical  with  "  rusty 
nail  tetanus."  The  term  "  idiopathic  "  should,  under  such  circum- 
stances, as  insisted  upon  by  P.  M.  Pilcher,  give  way  to  "  crypto- 
genetic  " ;  and  it  would  seem  to  me  that  certain  cases  of  tetanus 
usually  called  "  chronic  "  would  be  more  accurately  characterized 
as  "  sub-acute." 

Symptoms  and  Course. — Symptoms  may  begin  at  any  time 
from  two  days  to  several  weeks  after  infection.  In  the  new-born 
it  is  placed  between  the  second  and  fifteenth  day,  though  most  cases 
occur  in  the  first  week.  Usually  the  first  symptom  to  attract  atten- 
tion is  difficulty  in  swallowing.  Nurslings  attempt  to  take  the  nip- 
ple, but  cannot.  They  purse  up  the  lips  and  thrust  the  tip  of  the 
tongue  forward.  Older  patients'  difficulty  is  opening  the  mouth. 
The  symptoms  of  pain  or  stinging  at  the  site  of  the  wound  preced- 
ing the  onset  of  trismus  is  mentioned,  and  seems  probable.  But  it 
is  not  a  prominent  symptom.  The  stiffness  of  the  jaws  increases, 
with  cramp-like  pains  in  the  muscles.    The  muscular  tonic  rigidity 


VARIOUS    INFECTIONS   AND    THEIR   EFFECTS  143 

extends  to  the  muscles  at  the  back  of  the  neck ;  the  rotary  muscles 
of  the  neck  not  being  affected.  The  infant  tries  to  take  the  breast, 
but  cannot,  and  older  patients  are  hungry,  but  cannot  eat,  and  can 
only  drink  with  the  greatest  difficulty.  Attempts  to  place  anything 
in  the  mouth  excite  greater  spastic  rigidity  of  the  muscles.  An 
infant  will  have  occasional  exacerbations  of  the  tonic  spasm,  be- 
tween which  there  is  slight  relaxation.  The  rigidity  of  the  muscles 
now  extends  to  those  of  the  abdomen  and  back.  The  abdomen 
becomes  as  hard  as  a  board  with  this  continuous  contraction.  The 
arms  and  legs  may  be  extended  and  rigid,  or  with  spasm  in  the 
pectorals  the  arms  may  be  held  stiffly  upon  the  chest.  The  spas- 
modic contraction  of  the  facial  muscles,  particularly  of  the  risorius, 
produces  the  risus  sardonicus.  (See  Fig.  32.)  The  nerves  of 
sight  and  hearing  and  the  skin  become  painfully  sensitive  to  irri- 


FiG.  32.  Tetanus,  at  St.  Clair  Hospital.  Note  the  stiffly  locked  jaw,  sar- 
donic grin,  tightly  closed  eyes,  the  abdominal,  back  and  post  cervical 
muscles  in  rigid  contraction ;  lower  extremities  held  in  extension.  In 
this  case  the  pectorales  were  contracted,  holding  the  arms  as  seen. 
Photograph  taken  in  the  interval  of  convulsions.  Infection  gained  en- 
trance by  a  splinter  of  wood  in  sole  of  right  foot,  some  five  weeks  pre- 
vious to  the  onset  of  tetanus.  At  the  time  of  the  illness  the  splinter  was 
found  in  a  perfectly  empty  and  dry  abscess  cavity  just  beneath  the  sole, 
with  no  signs  of  present  inflammation  thereabout.  Vigorous  treatment 
including  antitetanic  serum  failed  to  save  him. 

tation.  A  loud  sound,  a  bright  light,  or  a  current  of  cold  air  may 
be  sufficient  to  excite  a  more  dntense  spasm  of  all  the  affected 
muscles.  Spasms  occur  at  intervals  without  any  special  exciting 
cause  and  may  bow  the  patient  so  powerfully  backward  that  only 
his  head  and  heels  touch  the  bed,  his  body  arched  in  a  half  circle 
(opisthotonos).  The  contractions  may  be  in  some  cases  forward 
(emprosthotonos),  or  latterly  (pleurosthotonos),  and  be  so  power- 
ful as  to  produce  rupture  of  muscles.  The  nervous  irritability  may 
be  so  hyperesthetic  that  to  jar  the  bed  or  slam  a  door  will  precipi- 
tate a  convulsion.  At  the  beginning  of  a  convulsion  there  is  often 
a  slight  cry  or  moan  forced  from  the  patient  by  the  sudden  mus- 
cular contractions.  The  sphincters  are  contracted,  and  urine  and 
feces  may  be  retained.     Cases  of  rupture  of  the  bladder  liavc  been 


144  SURGICAL   DISEASES    OF   CHILDREN 

recorded.  The  contractions  of  the  muscles  are  extremely  painful. 
The  patient  retains  consciousness  throughout  the  sickness,  suffers 
excruciatingly  from  the  spasms,  and  also  from  thirst  and  hunger. 
Fever  is  not  a  marked  or  characteristic  symptom  until  toward  the 
last,  when  it  takes  a  rapid  and  extreme  elevation.  It  may  range 
from  normal  to  102  for  three  or  four  days,  and  then  run  up  to  105, 
106,  and,  as  the  fatal  end  approaches,  to  108.  It  has  been  known 
to  rise  after  death  to  113.  The  pulse  varies  with  the  temperature, 
and  the  respiration  with  the  spasm  of  the  respiratory  muscles. 
Death  usually  occurs  in  from  one  to  six  days,  from  exhaustion  or 
asphyxia  due  to  spasm  of  respiratory  muscles.  There  is  great 
emaciation. 

Chronic  Tetanus^  so  called,  is  a  variety  which  comes  after 
a  longer  period  of  incubation,  and  runs  a  milder  and  much  more 
prolonged  course.  While  nearly  the  same  train  of  symptoms  are 
presented,  they  are  so  much  modified  in  degree  that  the  patient 
may  endure  them  for  several  weeks  or  for  as  long  as  two  months, 
and  may  end  in  recovery  or  in  death  from  exhaustion. 

Tetanus  Cephalicus  or  Tetanus  Facialis  is  a  variety  fol- 
lowing linjuries  about  the  head  or  face.  The  muscles  involved  are 
only  those  of  the  face,  neck  and  esophagus,  sometimes  of  the  ab- 
domen.   It  usually  runs  a  milder  course,  and  may  end  in  recovery. 

Diagnosis. — The  diagnosis  when  the  disease  is  fully  developed 
is  not  difficult.  A  history  of  trauma,  slight  or  severe,  recent  or 
some  weeks  previous,  should  be  inquired  for.  In  new-born  infants 
there  is  always  the  recent  trauma  of  a  severed  umbilical  cord,  the 
most  frequent  port  of  entry,  and  a  possibility  of  some  obstetric 
abrasion.  In  infants  the  spasms  due  to  intracranial  injury,  or 
from  spasmodic  laryngitis,  or  laryngismus  stridulus,  should  be  dif- 
ferentiated. This  can  generally  be  done  by  attention  to  the  peculiar 
grouping  of  the  spasmodic  muscles  in  tetanus.  There  is  a  certain 
amount  of  resemblance  between  tetanus  and  strychnine  poisoning. 
In  the  latter  there  is  not  that  contraction  of  the  jaw  muscles  early 
in  the  case,  but  only  at  the  last.  The  spasms  are  quickly  repeated 
clonic  spasms,  with  complete  relaxation  between,  quite  different 
from  the  continuous  rigidity  of  the  affected  muscles  in  tetanus. 
There  is  no  foaming  at  the  mouth  in  tetanus.  Hysteria  of  so 
marked  a  type  as  to  raise  a  question  of  diagnosis  would  not  be 
apt  to  occur  in  a  child.  I  have  once  seen  it  in  an  adolescent  hobble- 
dehoy so  violent  as  to  raise  the  discussion.  But  the  symptoms  were 
variable  and  inconstant,  and  the  mental  state  pointed  to  hysteria.^ 
In  hydrophobia  there  is  almost  invariably  a  well-established  history 
of  the  bite  of  an  animal,  and  the  muscles  affected  are  first  and 
principally  those  of  deglutition  and  respiration.  In  hydrophobia 
1  Case  seen  with  Dr.  I.  C.  Carlisle. 


VARIOUS    INFECTIONS    AND   THEIR   EFFECTS  145 

the  patient  is  maniacal  and  restless,  while  in  tetanus  the  mind  is 
clear  and  he  keeps  as  quiet  as  possible. 

Prognosis. — The  prognosis  has  been  pretty  clearly  indicated  in 
the  foregoing-  account.  In  tetanus  of  the  new-born  and  acute 
tetanus  of  older  children  it  is  bad.  Anti-tetanic  serum  may  change 
this.  But  as  yet  one  does  not  feel  confident  in  giving  much  hope 
of  recovery  in  the  well-developed  case.  As  a  rule,  the  later  after 
the  infection  the  disease  begins  to  manifest  its  presence  the  better 
the  prognosis.  The  chronic  case  of  less  severe  grade,  or  the  ceph- 
alic form,  may  recover  even  under  the  older  methods  of  treatment, 
if  they  are  thoroughly  carried  out. 

Prophylaxis. — In  view  of  the  deadly  nature  of  this  disease 
and  the  terrible  suffering  it  causes,  every  possible  effort  should  be 
made  to  prevent  it.  Every  physician,  midwife,  nurse  and  mother 
should  know  what  disastrous  results  may  follow  the  lack  of  asepsis 
in  the  care  of  the  umbdlical  wound,  and  of  any  other  wound  upon 
the  infant,  and  if  a  case  occurs  in  the  practice  of  physician,  mid- 
wife or  nurse,  practice  should  be  suspended  pending  a  searching 
investigation  followed  by  rigid  antisepsis.  Such  deadly  playthings 
as  the  toy  pistol  should  be  abolished  throughout  the  country,  as 
has  been  attempted,  in  part  successfully,  in  a  few  cities.  In  case 
of  any  wound,  however  trifling,  especially  upon  hand  or  foot,  there 
should  be  a  proper  cleansing  and  an  antiseptic  dressing.  If  it  be 
a  lacerated  or  a  punctured  wound,  the  greatest  care  should  be 
taken  to  lay  it  open  to  the  bottom,  clean  it  surgically  clean,  dress 
it  open,  and  change  the  dressings  until  it  is  healed.  Parents  and 
children  should  be  warned  that  such  care  is  necessary.  Some  sur- 
geons are  advocating  the  use  of  immunizing  doses  of  anti-tetanic 
serum  in  every  '''  Fourth-of-July  "  casualty,  rusty-nail  accident,  or 
wound  received  in  a  garden,  field  or  barnyard.  Unless  the  disease 
were  known  to  be  epidemic,  or  endemic  in  that  locality,  this  pre- 
caution would  seem  unnecessary  if  those  before  mentioned  were 
taken. 

Treatment  of  the  Wound. — In  all  cases  of  tetanus  search 
should  be  made  for  the  atrium  of  infection.  In  some  cases  it  is 
only  too  obvious ;  in  others  it  may  be  a  forgotten  burn  or  a  splinter 
under  the  nail.  If  it  is  an  unhealed  umbilicus,  this  should  be 
thoroughly  cleansed  with  antiseptics,  lest  more  of  the  poison  be 
generated  and  absorbed.  Possibly  it  is  because  of  antisepsis  that 
the  use  of  turpentine  on  the  umbilicus  has  a  reputation  among  the 
laity  in  some  parts  of  the  South  for  the  cure  of  "  nine-day  fits." 
With  the  patient  under  anesthesia,  an  abscess  or  a  discharging 
wound  should  be  laid  open,  cleansed,  scraped,  excised,  or  cauter- 
ized, as  seems  necessary  to  get  rid  of  suspicious  tissue.  In  certain 
cases  amputation  may  be  expedient. 


146  SURGICAL   DISEASES    OF    CHILDREN 

Treatment  ivith  Tetanus  Antitoxin. — The  most  recent  and  most 
promising  treatment  is  that  by  anti-tetanic  serum.  Enough  experi- 
ence of  methods,  dosage  and  results  has  not  yet  been  obtained  to 
give  definite  directions  nor  to  predict  the  effect  to  any  certainty. 
Knowledge  will,  it  is  hoped,  advance  rapidly,  and  what  is  now 
written  ^  may  be  superseded  by  the  time  it  is  read  in  print.  Behring 
and  Kitasato  were  first  to  produce  an  anti-tetanic  serum.  It  is 
now  made  and  marketed  by  Behring,  by  the  H.  K.  Mulford  Com- 
pany, Parke  Davis  &  Co.,  and  other  manufacturers.  Tetanus  anti- 
toxin has  no  power  to  destroy  the  bacteria  nor  to  prevent  the  pro- 
duction of  their  toxines,  but  it  has  the  power  to  neutralize  the 
toxines.  Immunity  to  their  effects  has  been  produced  in  animals, 
and  cases  have  been  reported  of  its  successful  use  in  tetanus  neo- 
natorum, and  in  traumatic  tetanus.  One  thing  is  certain,  if  it  is 
to  be  useful  it  must  be  used  early  in  the  case  and  in  very  large 
doses.  It  is  advised  to  use  in  acute  cases  from  three  to  fifteen 
thousand  units  every  four,  six  or  eight  hours.  Some  advise  the 
use  of  fifteen  to  thirty  thousand  units  at  the  same  intervals.  An 
immunizing  dose  is  said  to  be  fifteen  hundred  units.  Others  rec- 
ommend thirty  to  sixty  c.c,  and  again  others  200  to  300  c.c.  in 
twenty-four  hours.  Inasmuch  as  the  strength  of  the  antitoxin  is 
not  universally  standardized,  these  directions  become  all  the  more 
indefinite.  It  may  be  used  by  the  familiar  subcutaneous  method, 
or  the  slightly  less  convenient  intravenous  method.  To  come  still 
more  quickly  in  contact  with  the  toxines,  it  is  still  better  to_  inject 
the  antitoxin  into  the  spinal  canal  by  lumbar  puncture.  After  al- 
lowing from  5  to  15  c.c.  of  cerebro-spinal  fluid  to  escape,  an  equal 
quantity  of  the  antitoxin  is  injected.  To  get  still  nearer  to  the  af- 
fected centers  Raoux  and  Kocher  have  advised  injecting  it  into  the 
brain  or  lateral  ventricles.  Those  who  accept  the  theory  of  the  trans- 
mission of  the  toxines  from  the  wound  along  the  nerves  to  the 
spine,  and  hold  that  it  cannot  travel  peripherally,  and  only  slowly 
in  the  afferent  direction,  advocate  both  intraneural  and  intraspinal 
injection  of  the  serum,  five  or  ten  minims  for  a  nerve  trunk  and 
fifty  or  sixty  for  the  spinal  cord.     These  doses  are  for  adults. 

Other  Treatment  and  General  Management  are  very  important. 
Special  efforts  should  be  made  to  support  the  patient  with  food 
and  drink.  These  may  have  to  be  given  through  a  tube  passed  by 
way  of  a  nostril  into  the  stomach.  This  is  a  much  better  method 
than  rectal  feeding.  Medicines  can  be  given  in  the  same  way. 
Subcutaneous  injections  of  normal  or  deci-normal  salt  solutions, 
and  of  sterilized  olive  oil  or  oil  of  sweet  almonds,  are  valuable. 
Cold  to  the  spine,  as  ice-bags,  et  cetera,  has  been  much  recom- 
mended.   One  does  not  know  whether  it  does  any  good,  and  patients 

1  March,   1908. 


VARIOUS   INFECTIONS   AND   THEIR   EFFECTS  147 

object  to  lit.  When  they  seem  irritated  thereby  I  do  not  use  it. 
Hot  baths  appear  more  soothing ;  and  they  promote  perspiration, 
which  may  be  eUminative.  The  patient  should  be  undisturbed ;  no 
light,  noises  or  jars  allowed  to  irritate  his  nerves. 

Drug  Treatment. — No  known  drug  has  any  specific  action  in 
this  disease,  and  yet  drugs  are  valuable.  All  that  can  be  hoped  for 
from  them  is  to  control  in  some  measure  the  morbid  excitability  of 
the  motor  centers  and  relieve  pain.  Those  most  used  have  been 
chloral,  the  bromides,  chloroform  and  ether,  and  physostigma.  Po- 
tassium bromide  should  probably  be  used  first  for  spinal  sedation 
without  cardiac  depression.  Full  doses  should  be  given,  four  to 
eight  grains  every  two  hours  to  a  new-born  babe,  and  to  older 
children  in  proportion.  A  child  of  six  years  will  take  from  twenty 
to  forty  grains,  always  well  diluted.  Chloral  in  combination  with 
the  bromide  is  much  more  efficient  in  relaxing  spasm  and  procur- 
ing sleep.  But  chloral  is  somewhat  depressing.  Chloral  probably 
renders  safer  the  after  use  of  physostigma.  The  latter  can  and 
preferably  should  be  used  in  the  form  of  eserine  hypodermically. 
Chloroform  or  ether,  or  the  same  in  combination  with  oxygen,  may 
be  used,  intermittently  as  required,  to  relieve  the  intensity  of  the 
spasms.  Morphine  is  a  valuable  remedy  in  relieving  the  cramp- 
like pains  due  to  the  muscular  contractions.  Preferably  it  should 
be  injected  dnto  the  affected  muscles.  If  used  in  infants  their 
extreme  susceptibility  to  this  drug  should  be  remembered. 

I  have  no  experience  with  curare,  nor  with  the  carbolic  acid 
treatment  of  Bacelli,  Kocher  and  others.  The  latter  recommends 
subcutaneously  the  use  of  carbolic  acid  in  three  per  cent,  solution, 
injecting  fifteen  minims  every  two  hours  (adult  dose).  It  is 
thought  to  diminish  the  reflex  excitability  of  the  cord,  and  also  to 
have  an  antiseptic  action,  and  is  said  to  show  no  symptoms  of  car- 
bolic acid  poisoning.  I  should  try  it  only  with  much  caution  in  a 
child,  in  view  of  the  great  susceptibility  of  the  young  to  poisoning 
by  phenol. 

OTHER  INFECTIONS 

There  are  still  other  infectious  diseases  very  common  in  in- 
fancy and  childhood,  not  ordinarily  thought  of  in  this  connection, 
and  yet  bearing  a  relation  because  of  their  complications,  or  se- 
quellse,  or  remote  effects,  to  pediatric  surgery.  For  instance, 
measles,  which  notoriously  leads  to  involvement  of  the  lymphatics, 
to  otorrhea,  not  infrequently  to  croup,  and  too  often  to  tuberculosis, 
with  its  numerous  surgical  manifestations.  The  germs  of  pneu- 
monia are  well  known  as  frequent  causes  of  empyema,  of  joint  and 
bone  inflammations,  and  of  abscess  formation  in  many  parts  of 
the  body.  Influenza  powerfully  predisposes  to  infection  by  the  pyo- 
genic organisms,  and  together  they  bring  about  ^b^cesses  in  the 


148  SURGICAL   DISEASES    OF    CHILDREN 

accessory  sinuses,  otorrhea,  mastoiditis,  and  other  bone  diseases, 
and  inflammations  of  pleura  and  pericardium.  Mumps  has  its  spe- 
cial predilection,  in  addition  to  the  salivary  glands,  for  the  testicles 
and  ovaries.  Pertussis  adds  danger  to  anesthesia,  and  interdicts 
operations  upon  the  palate,  lips  or  abdomen.  Smallpox  has  its 
joint  and  suppurative  complications  and  sequellse.  Chicken-pox 
occasionally  becomes  gangrenous,  and  vaccinia  septic,  and  either  of 
them  when  pustular  is  capable  of  infecting  a  wound.  Typhoid  fever 
rarely  causes  intestinal  perforation  in  the  young,  but  besides  gan- 
grene, it  is  capable  of  producing  abscesses,  arthritis,  and  periostitis. 
Cerebro-spinal  meningitis  sometimes  has  articular  complications ; 
and,  moreover,  there  is  hope  that  in  cases  of  purulent  meningitis  a 
method  may  be  found  of  attacking  it  surgically  for  drainage  and 
disinfection. 

ACTINOMYCOSIS 

The  actinomycis  is  one  of  the  ray  fungi.  It  is  not  too  small 
to  be  seen  by  the  naked  eye  as  a  yellowish  speck,  and  looks,  under 
a  magnifying  glass,  something  like  a  tiny  yellow  chrysanthemum. 
It  can  propagate  in  living  tissues,  and  in  man  usually  is  a  mixed 
infection,  ordinary  pyogenic  organisms  being  also  present.  It  pro- 
duces chronic,  almost  painless,  swellings  which  break  down  and 
discharge  pus  in  which  the  minute  yellow  specks  may  be  seen  and 
may  be  felt  as  gritty  particles  beneath  the  finger.  The  fungus 
affects  grazing  animals  and  the  human  species,  being  rare  in  the 
latter.  In  cattle,  infection  about  the  mouth  or  jaw  is  most  common, 
and  is  known  as  "  lumpy  jaw."  It  sometimes  appears  in  the  lungs 
or  intestines,  as  well  as  the  jaws,  or  elsewhere,  even  destroying 
bone,  both  in  man  and  animals.  Besides  the  local  trouble  it  causes 
emaciation  and  weakness. 

Diagnosis. — It  has  been  mistaken  for  tuberculosis,  syphilis, 
sarcoma  or  cancer.  When  there  is  a  discharge,  as  is  almost  invari- 
able, the  presence  of  the  little  yellow  fungi,  containing  the  gritty 
calcium  particles,  readily  establishes  the  diagnosis. 

Prognosis. — The  prognosis  depends  upon  the  location,  as  to 
accessibility  for  removal. 

Treatment  consists  in  radical  extirpation. 

GANGRENE,    INFECTIOUS    AND    NON-INFECTIOUS 

Gangrene  may  be  infectious  or  non-infectious.  It  may  occur 
in  the  child  from  traumatism  in  all  its  varieties,  including  the  acci- 
dental strangulation  of  parts.  It  may  be  caused  by  disorder  of 
the  nervous  system,  as  in  Raynaud's  disease ;  to  the  action  of  drugs, 
as  in  ergotism;  or  to  the  local  action  of  chemicals,  as  in  carbolic 
acid  gangrene ;  or  to  constitutional  diseases,  as  in  hemophilia  and 
the  diabetes  that  comes  about  the  period  of  puberty ;  or  to  infec- 


VARIOUS    INFECTIONS    AND    THEIR    EFFECTS 


149 


tion  by  the  bacillus  of  malignant  edema  or  other  organisms ;  or  to 
a  combination  of  morbid  influences,  often  including  a  mixed  infec- 
tion, complicating  or  following  such  diseases  as  scarlet  fever, 
measles,  varicella,  and  erysipelas,  typhoid  and  other  fevers.  In 
fact,  the  possible  causes  include  all  those  which  produce  the  dis- 
ease in  adults  excepting  senile  changes. 

Traumatic  Gangrene  may 
occur  after  fracture  or  crush  of 
an  extremity  or  the  swelling  which 
follows  and  cuts  ofif  the  circula- 
tion or  the  innervation.  Injuries 
of  or  near  large  vessels  or  nerve 
trunks  should  be  very  closely 
watched  for  such  an  untoward 
event.  Cases  have  occurred  in 
which  the  application,  too  firmly, 
of  the  splint  or  bandage  without 
allowing  for  inevitable  swelling, 
has  done  more  than  the  original 
injury  to  produce  gangrene.  It 
is  very  easy  in  the  small,  frail 
limbs  of  a  child  to  apply  the  Es- 
march  bandage  too  tightly  or  to 
keep  it  on  too  long,  and  as  a 
result  produce  a  painful  edema  of 
the  limb,  and  perhaps  gangrene 
of  the  margins  of  the  wound,  if 
not  worse.  Gangrene  of  intestine 
will  occur  in  strangulated  hernia, 
the  same  as  in  the  adult.  The 
constriction  of  paraphimosis  has 
been  known  to  cause  gangrene  of 
the  prepuce,  or  of  the  urethra,  or 
of  these  structures  and  the  glans 
penis.  A  metal  ring  mischiev- 
ously slipped  upon  the  penis  has  produced  the  same  result  (Owen), 
and  one  has  averted  similar  catastrophies  from  the  use  of  a  rubber 
band  and  of  a  steel  band  only  by  their  timely  removal  and  the  use 
of  hot  baths  to  restore  the  circulation. 

Carbolic  Acid  Gangrene. — This  form  of  gangrene  is  not 
uncommon.  One  has  met  it  a  number  of  times  in  varying  degrees. 
Other  acids,  and  also  alkalies,  as  caustic  potash  applied  in  solu- 
tion, would  produce  a  similar  effect,  but  not  so  painlessly.  Most 
of  the  cases  occur  from  the  domestic  use  of  carbolic  acid  as  a 
dressing  for  some  minor  injury.     (See  Fig.  2^.)     Quite  a  large 


Fig.  S3.  Carbolic  acid  gangrene. 
Boy  aged  4^  years,  had  pinched 
finger  sHghtly  in  a  door.  Offi- 
cious neighbors  advised  "phenol." 
A  bandage  was  applied  and 
saturated  with  it,  result  gan- 
grene requiring  amputation.  Fin- 
ger mummified.  The  blebs  show 
the  line  of  demarkation. 


150  SURGICAL   DISEASES    OF   CHILDREN 

number  of  instances  are  to  be  found  in  the  literature.  "  Gangrene 
may  be  produced  by  a  i  per  cent,  solution  of  carbolic  acid  in 
twenty- four  hours  (Bruns  and  Peraire),  in  twelve  hours  by  a  2 
per  cent,  solution  (Levai),  and  in  three  or  four  hours  if  the  so- 
lution is  more  concentrated  (Kortum).  Various  theories  have  been 
advanced  to  explain  these  cases.  Kortum  thought  gangrene  was 
caused  by  the  action  of  carbolic  acid  upon  the  trophic  and  vascular 
nerves.  Frankenbueger  showed  by  experiments  on  animals  that 
dilute  solutions  of  carbolic  acid  would  produce  complete  destruc- 
tion of  parts  to  which  they  were  applied.  He  thought  the  action 
was  exerted  directly  upon  the  red  and  white  corpuscles,  producing 
stasis  and  thrombosis.  Levai  showed  by  experiments  that  the 
death  of  the  part  is  due  to  a  direct  chemical  action  on  all  the 
tissues."  ^ 

HEMOPHILIAC  Gangrene. — Hsemophilia,  a  constitutional  dis- 
ease of  unknown  origin  (see  section  on  Hemophilia),  has  been  re- 
ported as  a  cause  of  gangrene. 

Diabetic  Gangrene. — The  diabetes  of  children  about  the  age 
of  puberty  is  given  by  D'Arcy  Power  as  one  of  the  causes  of  gan- 
grene. Diabetes  in  early  life  is  not  a  very  common  disease,  and 
gangrene  as  a  result  must  be  quite  rare  at  this  age,  most  cases 
occurring  past  middle  life,  even  past  the  fiftieth  year. 

Typhoid  Gangrene. — Keen  considers  the  influence  of  age  in 
the  production  of  typhoid  gangrene  as  not  very  marked.^  Of  140 
cases  at  all  ages  which  he  collected,  there  were  under  15,  26  cases ; 
from  15  to  25,  64  cases ;  after  25,  50  cases.  This,  he  considers,  will 
not  differ  much  from  the  normal  age-distribution  of  typhoid.  But 
Drewitt,  as  stated  by  Power,^  thinks  that  gangrene,  usually  em- 
bolic in  origin,  is  more  frequent  in  children  than  in  adults ;  and  he 
offers  in  explanation  the  very  plausible  reason  that  the  young  heart 
is  able  to  hold  out  to  the  end  in  cases  of  typhoid,  where  older  hearts 
would  fail,  and  though  gray  and  bloodless,  are  still  able  to  contract 
on  the  half  dried-up  and  clotting  blood  stream. 

Emphysematous  Gangrene  (Malignant  Edema,  Spreading 
Traumatic  Gangrene)  must  be  extremely  rare  among  children 
in  this  country.  It  is  an  infection,  spreading  so  rapidly  that  it  may 
involve  a  whole  limb  and  invade  the  trunk  in  a  few  hours,  with  a 
tense  and  painful  swelling,  dark  red  or  purple  in  color,  becoming 
dusky  and  mottled,  then  vesicular,  boggy,  and  crackling  under  the 
examining  finger,  with  gases  among  the  tissues.  These  become  a 
soft  black  mass.    The  patient  sinks  into  a  very  low  state  and  dies 

*  A.  C.  Wood,  Bryant  and  Buck,  Am.  Practice  of  Surgery. 
2 "  Surgical    Complications    and    Sequels    of    Typhoid    Fever,"    W.    W. 
Keen,  p.  73. 

3 "  Surgical  Diseases  of  Children,"  D'Arcy  Power,  p.  15. 


VARIOUS   INFECTIONS   AND   THEIR   EFFECTS  151 

from  the  presence  of  the  gases  in  the  blood,  in  the  same  manner 
as  when  air  enters  the  veins ;  or  in  some  cases  mider  treatment  he 
recovers.  The  disease  is  attributed  to  an  anserobic  bacilhis  dis- 
covered by  Koch.  Morphologically  it  resembles  the  bacillus  of 
anthrax,  and  also,  like  anthrax,  inhabits  garden  soil.  It  is  motile 
and  spore-forming  in  the  living  body.  It  is  said  not  to  produce 
gas  excepting  in  company  with  ordinary  germs  of  putrefaction. 
Various  other  anaerobic  bacilli  with  pus  cocci  are  capable  of  pro- 
ducing gangrene  with  gas  formation,  which  cannot  be  differenti- 
ated clinically.  Not  all  cases  of  emphysematous  gangrene  are  ma- 
lignant edema. 

Treatment  consists  in  free  incisions,  or  excision  of  the  dis- 
eased area,  or  amputation  high  above  the  disease.  Antiseptic  dress- 
ings, and  usually  heat.  Internally,  stimulation  and  supporting  treat- 
ment. 

Raynaud's  Disease. — Children  are  subject  to  Raynaud's  dis- 
ease, if  that  be  indeed  an  entity;  so  many  cases  are  reported  which 
seem  quite  as  probably  resultant  from  some  other  cause  or  a  com- 
bination of  causes.  Yet  some  seem  to  present  all  characteristics  de- 
scribed by  Raynaud,  excepting  perhaps  that  of  symmetry,  for  the 
disease  is  more  often  bilateral.  It  affects  the  fingers  and  toes,  even 
up  to  the  wrists,  ankles  or  knees,  or  the  tip  of  the  nose,  the  cheeks 
or  the  ears.  A  period  of  local  syncope  is  followed  by  a  period 
of  local  asphyxia,  and  this  by  gangrene,  either  moist  or  dry.  After 
a  long  period  of  parsesthesia  of  the  part,  which  becomes  cold  and 
either  pale,  bloodless  and  painful,  or  livid  and  swollen,  the  gan- 
grene supervenes,  either  with  the  formation  of  blebs  or  with  grad- 
ual mummification.  The  patients  often  suffer  wiith  mental  depres- 
sion and  with  disturbances  of  sight,  taste,  hearing  and  cardiac 
action,  hemoglobinuria,  and  neuritis.  The  pathogenesis  of  the  dis- 
ease is  much  disputed,  the  majority  perhaps  maintaining  that  it  is 
due  to  vaso-motor  disorder  from  central  causes. 

Treatment. — The  treatment  of  Raynaud's  disease  is  directed  to 
the  neuropathic  condition,  locally  to  stimulate  the  circulation  by 
massage,  heat  and  galvanism.  Gangrenous  parts  should  be  re- 
moved, as  in  any  other  form  of  gangrene. 

Noma  (N.  pudendi,  N.  Vidvce,  N.  Scroti,  Gangrenous  Stoma- 
titis, Cancrum  Oris,  Water  Cancer,  &c.). — This  is  a  very  destruc- 
tive form  of  gangrene,  attacking  the  cheek,  gum,  nose,  ear,  or  the 
genitals  or  anus,  and  extending  to  adjacent  structures,  accom- 
panied by  great  prostration  and  often  terminating  fatally.  Noma 
is  not  a  common  disease,  nor  one  of  long  duration,  and  the  oppor- 
tunities to  study  it  are  not  of  the  best.  Many  theories  have  been 
held,  but  it  is  now  regarded  as  undoubtedly  of  infectious  origin. 
No  agreement  has  been  arrived  at  as  to  the  identity  of  the  germ, 


152 


SURGICAL   DISEASES    OF    CHILDREN 


though  a  number  of  observers  have  claimed  the  discovery.  It  is 
thought  to  abound  in  many  places,  but  in  the  form  of  spores  which 
cannot  attack  tissues  unless  a  previous  disease  has  rendered  them 
vulnerable ;  for  the  disease  usually  follows  one  of  the  other  infec- 
tions, notably  measles,  whooping-cough,  scarlet  fever  or  other 
specific  disease.  It  occasionally  occurs  in  children  debilitated  and 
cachectic  from  various  causes.  The  patients  are  from  three  to 
eight  years  of  age,  but  may  be  older  or  younger.  Noma  is  a  spread- 
ing gangrene  which  spares  no  tissue  with  which  it  comes  in  con- 
tact.    Power  describes  two  varieties  as  he  sees  it  among  the  neg- 


•       Fig.  34.     Cancrum  Oris.     Child  aged  5  years. — Dr.   Stewart  L.  IMcCurdy's 

Case. 

lected  poor  children  of  London ;  one  which  runs  an  acute  gangrenous, 
and  the  other  a  less  acute  phagedenic,  course,  the  slower  being  the 
more  usual.  I  have  seen  but  few  cases  in  this  country,  and  they 
were  rapid  in  their  course,  and  one  which  survived  was  extremely 
slow  in  convalescing,  and  the  frightful  gap  in  the  face  was  a  long 
time  in  cicatrizing. 

Symptoms. — The  disease  often  begins  in  the  cheek  near  the 
angle  of  the  mouth  (see  Figs.  34  and  35),  on  the  membranous  side, 
or  upon  the  lip,  or  the  gum ;  it  may  be  upon  the  labia-majora  or  else- 
where. Holt  describes  a  series  of  five  cases  in  a  hospital  ward 
(upon  whom  the  same  syringe  was  used  for  otorrhea)  in  which 
noma  began  in  the  deeper  structures  of  the  auditory  canal. 
Upon  mucous  membrane  it  begins  with  a  small  dark  spot, 
which  may  or  may  not  be  ulcerated  when  first  seen;  or  there 
may  be  vesicles  which  break  down  and  leave  an  ulcer  covered  with 
a  yellow  secretion.  The  surrounding  parts  become  greatlv  swollen 
and  brawny,  and  turn  blackish  and  necrotic.  If  upon  the  cheek  the 
disease  now  shows  through  upon  the  outside.     The  infiltration  fol- 


VARIOUS    INFECTIONS   AND   THEIR   EFFECTS 


153 


lowed  by  the  edema  and  by  the  necrosis  extends  wider  and  far- 
ther.    It  destroys  soft  parts,  alveolar  processes  or  bones. 

At  the  genitals  it  may  extend  to  pubis,  thigh  or  perineum,  and 
as  deep  as  it  is  wide.  After  the  gangrenous  process  has  gone  on 
for  several  days,  symptoms  of  septicemia  and  prostration  develop, 
often  with  diarrhea.  The  gangrenous  tissue  falls  away.  In  fatal 
cases  there  is  no  line  of  demarkation.  The  odor  is  extremely  of- 
fensive. Fever  may  range  from  102  to  105,  or  may  be  subnormal 
as  the  end  approaches  (Holt).  Pulse  very  feeble.  The  sloughing 
process  goes  on,  with 
greater  general  prostra- 
tion, perhaps  with  hemor- 
rhage or  septic  pneumonia, 
to  the  fatal  end. 

Diagnosis. — The  diag- 
nosis will  present  no  diffi- 
culty if  the  disease  is  borne 
in  mind.  Its  rarity  makes 
it  likely  to  be  unthought  of 
until  it  is  far  advanced. 

Prophylaxis  would  de- 
mand cleanliness  and  an- 
tisepsis in  all  cases  of  sto- 
matitis, vulvitis  and  ba- 
lanitis, however  simple 
they  may  appear,  with 
especial  attention  in  de- 
bilitated children.  A  case 
of  noma  should  be  strictly 
isolated. 

Treatment. — As  soon 
as  noma  is  recognized  the 
patient  should  be  anes- 
thetized, and  the  diseased  tissues  completely  excised,  beyond  the 
area  of  infiltration.  The  wound  should  then  be  cauterized  with 
the  Paquelin  cautery,  or  nitric  acid,  or  carbolc  acid,  afterward  neu- 
tralizing all  excess,  and  dressing  the  wound.  If  the  face  is  the 
seat  of  the  trouble,  the  child  should  be  placed  in  such  a  position 
that  the  discharges  will  not  be  drawn  into  the  larynx,  and  where- 
ever  located  the  wound  should  be  kept  well  cleansed  with  anti- 
septic solutions,  chlorate  of  potash,  peroxide  of  hydrogen,  per- 
manganate of  potash,  iodine,  and  irrigated  with  normal  salt  solu- 
tion. Diphtheria  antitoxin  and  anti-streptococcic  serum  have  been 
used  by  some  with  alleged  benefit.  Concentrated  food,  stimulants, 
as  whisky,  strychnia  and  quinia  are  indicated. 

The  resulting  scars  may  call  for  plastic  surgery. 


Fig.  35.     Cancrum  oris  in   a  Chinese 
child. — Dr.   W.   H.   Kinnear. 


CHAPTER  V. 

BURNS   AND    SCALDS 

The  subject  of  burns  and  scalds  is  a  rather  important  one,  for 
the  reasons  that  owing  to  the  ignorance,  carelessness  and  helpless- 
ness of  children  this  form  of  injury  is  very  common  among  them, 
and  that  with  them  the  injury  is  far  more  apt  to  be  dangerous  than 
with  their  elders. 

The  skin  and  deeper  tissues  of  the  child  are  so  much  more 
delicate  than  that  of  adults  that  they  are  damaged  by  a  lesser  degree 
of  heat  and  in  shorter  time,  and  experience  has  proven  that  the 
burns  and  scalds  of  apparently  equal  degrees  of  severity  are  more 
apt  to  prove  fatal  in  the  3'oung. 

It  seems  to  make  little  difference  in  the  effect  upon  living 
tissues  whether  heat  be  applied  in  the  form  of  flame  or  radiant  heat 
or  heated  substances.  Practically  the  greatest  number  of  extensive 
burns  are  received  either  by  the  clothing  burning  or  by  scalding 
with  water.  I  once  knew  a  child  scalded  and  blistered  from  the 
armpits  down  by  being  placed,  while  having  a  convulsion,  in  a 
bath  of  hot  mustard  water.  The  fatal  ending  of  the  case  resulted 
more  from  the  injury  than  from  the  disease.  Burning  by  contact 
of  a  hot-water  bottle  with  an  unconscious  or  paralyzed  child  is  an 
occurrence  one  meets  altogether  too  frequently.  (Fig.  36.)  As 
a  rule,  scalds  are  more  extensive  than  burns,  while  burns  extend 
more  deeply. 

The  effects  are  usually  described  in  three  degrees.  In  the 
first  degree  there  is  simply  h^^peremia  of  the  skin  caused  by  dilation 
of  the  superficial  blood-vessels  with  a  slight  exudation  of  serum. 
This  produces  moderate  swelling  but  no  vesication,  and  recovers 
with  no  trouble  beyond  the  loss  of  the  epidermis.  In  the  second 
degree  the  congestion  is  greater  and  the  serous  exudation  is  suffi- 
cient to  lift  the  epidermis  from  the  cutis  vera,  producing  vesicles 
or  blebs.  The  contents  of  these  blisters  are  thin  at  first,  but  later 
coagulate  and  become  jelly-like  and  may  become  bloody  or  purulent. 
If  infection  does  not  occur,  the  result  may  be  in  a  little  longer  time 
as  good  as  in  burns  of  the  first  degree,  restoration  without  scar. 
In  a  burn  of  the  third  degree  there  is  damage  deeper  than  the  epi- 
dermis. Blood  is  coagulated  and  blood-vessels  destroyed,  albumens 
are  also  coagulated,  connective  tissues  have  their  fluids  driven  out 

154 


BURNS   AND    SCALDS 


155 


by  the  heat.  The  result  is  disorganization  and  devitalization  of 
tissue,  shallower  or  deeper,  according  to  the  degree  of  the  heat  or 
the  length  of  time  during  which  it  was  applied,  even  to  the  destruc- 
tion of  bone  or  an  entire  extremity.  These  dead  tissues  must,  if 
the  patient  survives,  be  cast  of?  by  the  same  process  as  occurs  in 
gangrene  or  in  crushing,  and  healing  must  take  place  by  granula- 
tion, which  cannot  occur  without  the  formation  of  scar  tissue  with 
its  propensity  to  contract. 

As  in  any  other  wound,  there  is  liability  of  infection,  and  as  in 
any  infection  there  is  inflammation  with  pus  formation  and  all  the 


Fig.  2,6.     Burn  of  the  feet  caused  by  applying  hot  water  bottle  to  an 
unconscious  child.     One  toe  and  meta-tarsal  necrotic. 


dangers  of  septicemia,  pyemia,  and  that  train  of  evils  which  follows 
infections. 

The  dangers  from  burns  are  in  shock,  putrefactive  toxemia, 
besides  the  chances  of  a  mixed  infection  with  tetanus  or  erysipelas ; 
complications  in  the  form  of  congestions  of  internal  organs,  the 
intestinal  tract,  lungs  or  brain ;  nephritis ;  ulceration  of  the  duo- 
denum ;  disfigurement  by  resultant  scars,  and  further  disfigurement 
and  even  deformity  and  loss  of  function  by  cicatricial  contraction. 
There  is  a  more  remote  danger  of  chronic  ulceration,  or  the  growth 
of  keloid  or  epithelioma  in  the  scar  tissue. 

Shock  is  the  first  and  great  danger.  It  is  present  in  proportion 
to  the  area  rather  than  to  the  depth  of  the  burn.  Pain  is  greater 
if  cutaneous  nerves  are  only  injured  and  exposed  than  if  they  are 
destroyed.  Of  the  cases  of  burns  that  cause  death  promptly  after 
injury  a  large  proportion  are  burns  of  the  second  degree.  The 
symptoms  may  be  those  usual  in  shock,  the  quick  and  feeble  pulse, 


IS6  SURGICAL   DISEASES    OF    CHILDREN 

cold  skin,  and  subnormal  temperature,  abated  reflexes,  depression 
of  the  mental  acuteness  without  loss  of  consciousness.  Sometimes  a 
patient  is  extremely  restless  and  complaining,  nearly  all  are  very 
thirsty,  and  some  vomit.  Death  may  occur  by  collapse  or  coma. 
In  case  of  recovery  from  shock,  fever  is  apt  to  supervene,  and  the 
subsequent  course  will  depend  upon  whether  septicemia  or  other 
complication  is  present.  The  fever,  the  congestions  of  internal 
organs,  and  other  evidences  of  general  and  local  disorders  remote 
from  the  wound,  have  received  much  study  and  are  yet  not  fully 
explained.  Some  claim  that  the  arrest  of  functional  activity  of  the 
skin  causes  toxemia  from  poisons  retained  in  the  system,  and  point 
to  the  fact  that  the  extent  of  the  area  burned  is  a  large  factor  in  the 
case.  Others  look  upon  the  same  fact  as  an  evidence  that  it  is 
the  excessive  irritation  of  an  immense  number  of  peripheral  nerves 
that  exhausts  the  nervous  system  and  lowers  vascular  tension. 
Others  regard  resulting  conditions  as  sapremia  from  the  absorp- 
tion of  poisons,  non-infectious  in  origin,  at  the  wound.  Some 
investigators  lay  great  stress  on  the  destruction  of  red  blood  cor- 
puscles which  takes  place  with  burns,  and  consequent  hemoglobi- 
nuria, also  destruction  of  white  corpuscles  and  formation  of  thrombi 
in  capillaries.  On  this  theory  of  thrombosis  the  peculiar  ulcerations 
in  the  duodenum  are  explained.  Suppression  of  urine  is  common 
both  in  the  stage  of  shock  and  of  reaction,  but  although  conges- 
tions of  the  kidneys  occur  actual  inflammation  is  not  so  common. 
The  congestion  of  the  brain  may  produce  delirium,  that  of  the 
intestine  ulceration,  hemorrhage,  or  diarrhea,  and  that  of  the  pleurae 
and  lungs,  pneumonia. 

Diagnosis. — The  diagnosis  of  burns  would  seem  entirely  obvi- 
ous, yet  there  may  be  question  as  to  the  production  of  it,  especially 
in  the  absence  of  clear  history  or  in  medico-legal  cases.  Scalds  do 
not  destroy  the  hairs,  and  are  more  apt  to  be  equal  in  degree  over 
a  large  area.  The  burn  of  nitric  acid,  if  recent,  is  yellow,  that  of 
sulphuric  acid  reddish  or  rusty,  that  of  carbolic  acid  white ;  but  any 
of  these,  like  the  burn  of  caustic  potash  or  of  heat,  will  later  appear 
brown  or  blackish,  or,  occasionally,  a  washed-out  gray  color.  The 
eschar  does  not  separate  from  the  living  tissues  for  eight  or  ten 
days,  and  then  leaves  a  red  and  suppurating  ulcer  with  inflamed 
edges.  Burns  from  electrically  charged  wires  are  black  at  the  point 
of  contact,  which  is  surrounded  by  a  paler  and  drier  area.  An 
electric  burn  may  be  more  severe  beneath  the  surface  than  would 
at  first  appear. 

Prognosis. — The  prognosis  in  a  case  of  burn  is  more  grave  in 
the  young  than  in  the  adult  patient.  It  is  usually  said  that  a  burn 
of  the  first  degree  will  likely  prove  fatal  if  more  than  two-thirds 
of  the  skin  surface  is  burned,  and  a  burn  of  the  second  degree  will 


BURNS    AND    SCALDS  157 

cause  death  if  more  than  half  the  skin  is  damaged.  But  I  believe 
if  the  patient  is  a  young  child,  it  is  nearer  the  truth  to  say  that  if 
more  than  one-third  of  the  skin  surface  is  burned,  death  will  prob- 
ably ensue.  The  location  of  the  burn  or  scald  has  some  bearing  on 
the  prognosis.  Scald  of  the  glottis  gives  doubtful  prognosis.  If 
the  injury  be  located  upon  abdomen,  chest,  or  pelvis,  the  effect  will 
be  more  severe  than  if  at  were  elsewhere.  The  general  health  and 
vigor  of  a  patient  are  to  be  taken  into  consideration.  Infection  of 
the  wound  darkens  the  prognosis,  as  regards  life,  complications,  and 
scarring.  A  moderate  sized  burn  or  scald  of  the  first  degree  will,  if 
fairly  treated,  get  well  in  a  week  or  two,  leaving  only  redness,  which 
will  gradually  fade  into  normal  color.  A  burn  of  the  second  degree, 
if  kept  germ-free,  will  do  the  same  in  a  somewhat  longer  time.  The 
second  degree,  if  infected,  and  the  third  degree,  even  if  uninfected, 
will  result  in  scarring,  but  if  infected  in  much  worse  scarring.  Con- 
tractions are  disastrous  if  located  near  an  orifice,  as  mouth  or  eyes, 
or  at  the  flexures  of  joints,  as  upon  hand,  front  of  the  elbow  or 
axilla. 

Treatment. — The  treatment  of  burns  and  scalds  is  local,  gen- 
eral, and  that  of  complications  or  symptoms  which  arise.  It  may 
be  truthfully  said  that  the  treatment  of  these  injuries  has  often 
been  faulty  on  account  of  regarding  them  as  in  some  way  different 
from  other  wounds  and  not  applying  to  them  the  same  modern 
surgical  principles.  Doubtless  the  humane  desire  to  relieve  as 
speedily  as  possible  the  terrible  sufferings  of  the  patient  has  often 
induced  too  great  haste  in  covering  up  with  dressings  an  uncleansed 
wound-surface.  The  result  is  infection  with  the  possibility  of  all 
its  evils,  local  and  general.  The  burn  or  scald  should  be  treated 
as  one  would  a  crushed  or  lacerated  wound.  An  anesthetic  should 
be  given.  This  at  once  relieves  the  pain  and  helps  to  prevent  shock. 
During  anesthesia  the  wound  should  be  thoroughly  cleansed.  An 
excellent  plan  is  to  immerse  the  burned  parts,  if  necessary  the  wdiole 
patient,  in  a  bath  of  warm  normal  salt  solution,  or  sodium  bicar- 
bonate solution  of  the  same  strength.  If  the  burn  is  only  of  the 
first  degree,  or  blebs  have  not  yet  formed,  soap  may  be  used,  and 
the  water  changed  for  sterile  and  followed  by  an  antiseptic  solution 
and  sterile  water  again.  Some  would  use  ether  in  this  cleansing 
process.  If  blebs  have  formed,  or  it  be  an  ordinary  second  or  third 
degree  burn,  the  same  process  is  proper,  taking  care  to  remove 
shreds  of  tissues  and  all  impurities,  washing  with  a  i  to  40  solution 
of  carbolic  acid,  and  following  this  with  normal  salt  solution  or 
sterile  water.  It  is  not  necessary  to  remove  unbroken  blebs.  They 
should  be  snipped  open  with  sterile  scissors  to  evacuate  the  serum. 
Sometimes  in  the  healing  process  the  epidermis  forming  the  bleb 
r^Vinites   with   the   dermis.     The   cleansing   process    completed,    it 


158  SURGICAL   DISEASES    OF   CHILDREN 

remains  to  apply  a  sterile  protective  and  antiseptic  dressing.  Many- 
hospitals  have  a  stock  formula  for  dressing  burns ;  and  the  individ- 
ual surgeons  have  a  favorite  preparation,  all  proven  by  experience 
to  be  useful.  Outside  of  hospitals  it  often  happens  that  what  one 
v^ould  prefer  is  not  to  be  had  in  the  emergency,  so  a  number  of 
materials  and  methods  will  be  mentioned.  A  burn  or  scald  can  be 
treated  successfully  and  comfortably  in  a  continuous  bath  of  salt 
or  sodium  bicarbonate  solution,  or  a  4  per  cent,  boracic  acid  or  alumi- 
num acetate  solution,  or  sterile  water  at  a  comfortable  tempera- 
ture. Or,  if  the  surface  is  not  too  large,  in  a  one  per  cent,  carbolic 
solution ;  or  cloths  wet  in  these  solutions  and  kept  constantly  wetted 
may  be  used.  A  solution  of  picric  acid  in  water,  i  to  50  or  i  to  100, 
has  been  highly  praised.  The  old-fashioned  Carron  oil,  equal  parts 
linseed  oil  and  lime  water,  is  still  used  with  success.  Eucalyptol  may 
be  added  to  it  with  advantage.  The  oil  is  applied  by  saturating 
gauze  in  several  thicknesses  and  laying  it  on.  Ointments  of  boracic 
acid  I  per  cent.,  carbolic  acid  i  per  cent.,  carbonate  of  zinc  any 
strength,  plain  vaseline,  are  all  useful.  Some  prefer  dusting  powders 
of  boracic  acid,  salicylic  acid,  zinc  oxide,  dermatol  or  zinc  car- 
bonate or  bismuth.  These  powders,  excepting  perhaps  the  last  two 
mentioned,  are  not  as  comforting  to  the  wound  as  the  wet  dressings 
or  ointments.  Powders  are  useful  to  absorb  excessive  moisture. 
Outside  of  the  Carron  oil  gauze,  the  ointment  or  the  dusting 
powder,  gauze,  cotton,  and  a  light  roller  should  be  applied.  If  none 
of  these  are  obtainable,  lard,  molasses,  or  flour  may  serve  to  exclude 
the  air  and  protect  the  surface.  Dressings  should  be  ample  in  area. 
One  often  sees  a  dressing,  otherwise  well  done,  allow  exposure  to 
infection  at  some  small  angle  where  the  dressing  should  have  over- 
lapped the  wound  farther.  As  soon  as  the  wound  is  cleansed  and 
covered,  and  the  patient  allowed  to  emerge  from  anesthesia,  he 
should  receive  sufficient  morphia  to  soothe  his  sufferings,  and 
attention  directed  to  the  prevention  or  control  of  shock  by  the  use 
of  stimulants,  hot  bottles,  et  cetera.  (See  Section  on  Shock.) 
Normal  saline  enemata  assist  in  combatting  shock,  and  also  the 
inordinate  thirst  which  many  experience,  besides  having  a  diuretic 
effect  which  is  desirable.  In  addition  to  other  stimulants  I  have 
thought  camphor  (in  full  doses  hypodermatically  in  oil)  useful  in 
the  depression  with  restlessness  which  appears  in  these  cases.  The 
suppression  of  urine  must  be  met  with  the  free  use  of  water  gnd 
mild  diuretics  and  hot  packs,  the  diarrhea  by  bismuth  mixtures, 
and  the  fever  with  sponging,  the  delirium  with  the  ice  bag  or 
Leiter's  coil,  and  bromides.  The  dressing  should  not  be  changed 
too  soon,  but  care  should  be  taken  if  it  is  a  wet  or  oily  dressing  to 
pour  in  more  of  the  preparation  from  time  to  time  and  not  allow 
il;  to  get  dry.     At  the  later  dressings  sloughs  and  shreds  should 


BURNS  AND  SCALDS 


159 


be  removed  with  sterile  dressing  forceps  and  scissors,  the  wound 
irrigated  with  a  mild  antiseptic  solution,  like  carbolic  acid  followed 
with  sterile  salt  solution,  and  fresh  dressings  applied.  In  dressing 
an  extensive  burn  the  entire  area  should  not  be  uncovered  at  once, 
but  a  portion  at  a  time  uncovered,  cleansed,  and  covered  again. 
The  first  few  dressings  may  require  brief  general  anesthesia. 
Charred  or  necrotic  tissues  may  be  slow  to  separate  from  the  living 
in  burns  of  the  second  and  the  third  degree.  These  should  be  re- 
moved as  soon  as  possible.  At  the  same  time  the  margins  of  the 
wound  become  red  and  inflamed  and  need  attention,  often  requiring 
wet  dressings.  Usually  the  debris  is  allowed  to  clear  itself  away  too 
gradually,  then  granulations  appear,  and  if  the  burn  is  extensive  a 
mistake  in  the  treatment  now  occurs.  There  ensues  a  long  period  of 
painful  dressings  and  waitings,  with  all  the  chances  of  infection  and 
of  exhausting  the  patient,  or  of  exuberant  or  sluggish  granulations 
which  have  to  be  restrained  or  stimulated  by  touching  with  silver 
nitrate.  ^Meanwhile  granulation  tissue  is  forming  a  thick  layer  which 
will  subsequently  contract  and  form  a  hard  unyielding,  disfiguring, 
sometimes  even  deforming  and  impairing  cicatrix,  with  possibilities 
of  ulceration,  keloid,  or  epithelioma  later  in  life.  Of  course  it  is  ad- 
vised to  maintain  the  healing  surfaces  at  rest,  when  necessary  im- 
mobilizing them  with  splints,  and  this  in  a  position  of  greatest  exten- 
sion; also  that  adjacent  granulating  surfaces  (for  instance  between 
fingers)  should  be  separated;  and  also  that  careful  passive  move- 
ments should  be  persisted  in,  and  when  the  skin  is  closed  that  massage 
should  be  employed,  and  that  theosinamine  be  given  a  trial ;  and  that 
if  the  wound  surface  is  extensive  or  slow  in  closing  or  fails  to  close 
that  skin-grafting  should  be  resorted  to.  Now  all  these  are  useful 
measures  and  should  be  employed,  but  the  mistake  is  that  they  are 
commonly  adopted  too  late.  Especially  is  the  skin-grafting  post- 
poned far  too  long.  After  the  granulating  process  has  formed 
cicatricial  tissue  all  over  the  wound  it  avails  nothing  so  far  as  sub- 
sequent contractions  are  concerned,  to  cover  its  surface  with 
epithelium.  The  time  to  do  skin-grafting  is  immediately  the  ne- 
crotic tissue  separates  from  the  living  or  can  be  separated  by  sur- 
gical means.  Then  upon  a  healthy  and  aseptic  surface,  Thiersch  or 
Krause  or  Oilier  grafts  should  be  laid  and  covered  with  strips  of 
rubber  tissue  or  Cargile  membrane,  or  in  some  situations  generous 
flaps,  one-third  larger  than  the  surface  to  be  covered,  should  be 
transplanted,  accurately  adjusted  and  sutured.  Thus  avoid  contrac- 
tions. The  treatment  of  extensive  burn  contractions  by  plastic 
operations  is  one  of  the  most  alluring  and  sometimes  disappointing  in 
pediatric  surgery.  Simple  division  of  contracted  bands,  as  a  rule, 
avails  nothing. 


CHAPTER  VI 

THE   MUSCLES,   TENDONS,   FASCIA,   BURS^  AND 
CELLULAR   TISSUES 

Hematoma  of  the  Sternomastoid — Rheumatic  Myositis — ■ 
Other  Forms  of  Wry  Neck  (Torticollis) — Primary  Pro- 
gressive Myopathy — Tendons  and  their  Sheaths — Rheu- 
matic Tendinous  Nodules — Injuries  of  Tendons  and  their 
Sheaths — Operations  upon  Tendons — Fasciae — Burs^ — 
Cellular  Tissues. 

The  muscles  of  infants  and  young  children  are  not  only  smaller 
but  weaker  in  proportion  than  those  of  adults.  They  have  less 
tensile  strength  and  less  contractile  power.  They  occasionally  pre- 
sent anomalies  in  their  development.  They  are  subject  to  nearly 
all  the  diseases  and  injuries  which  occur  in  the  muscles  of  their 
elders.  Ossification  of  muscles  (myositis  ossificans),  does  not  often 
occur  in  childhood,  but  cases  are  reported  somewhat  rarely.  Pri- 
mary tumors  of  muscle,  while  rare  in  the  adult,  are  practically 
unthought  of  as  occurring  in  the  young.  Sarcoma,  beginning  in 
muscle  sheaths,  may  involve  the  muscle  itself.  Angioma  of  the 
cavernous  variety  may  appear  in  muscle,  and  also  angio-lipoma,  and 
dermoid  cysts  are  not  uncommon.  Contusions  of  muscle  are  com- 
mon, but  severe  sprains  or  strains  are  probably  not  as  frequent  as 
in  older  persons.  Spontaneous  rupture  by  muscular  action  is  un- 
known. 

HEMATOMA    OF    THE    STERNOMASTOID 

There  is,  however,  a  muscular  rupture  that  is  not  uncommon 
in  infants.  The  little  patient  may  be  brought  on  account  of  wry- 
neck or  on  account  of  a  small  tumor  which  is  felt  in  the  side  of  the 
neck.  The  tumor  may  be  found  about  the  middle  of  the  sterno- 
mastoid muscle  or  above  or  below  the  middle.  It  is  about  the  size 
of  a  filbert  or  a  hickorynut,  feels  quite  firm  and  is  evidently  within 
the  muscle-sheath.  There  is  no  discoloration  of  the  skin.  If 
the  babe  is  but  a  week  or  two  old  the  tumor  may  be  slightly  tender 
to  the  touch.  Later  there  is  no  tenderness.  The  head  is  held  toward 
the  affected  side,  with  the  chin  turned  toward  the  opposite  side. 
In  the  majority  of  cases  the  tumor  is  on  the  right  side.  In  rare 
instances  each  side  has  a  tumor.    The  origin  of  this  condition  is  a 

1 60 


MUSCLES,  TENDONS   AND    CELLULAR   TISSUES  i6i 

partial  rupture  of  the  sternomastoid  during  the  birth.  In  the 
greater  number  of  cases  inquiry  will  elicit  the  statement  that  it 
was  a  breech  presentation ;  and  while  it  is  probable  that  traction 
upon  the  feet  or  body  by  the  accoucheur  in  his  efforts  to  deliver  the 
head  may  have  caused  the  injury,  it  is  no  evidence  that  unnecessary 
force  was  used,  for  cases  have  occurred  in  easy  labors  in  which 
the  head  was  born  first,  in  which  no  force  was  used,  and  some  in 
which  no  attendant  was  present.  The  partial  rupture  of  the  muscle 
causes  a  hemorrhage  confined  within  its  sheath,  a  slight  inflamma- 
tory action  follows,  the  blood  clot  and  the  inflammatory  exudate 
constituting  the  tumor.  This  is  partly  absorbed  or  converted  into 
fibrous  tissue,  and  after  three  or  four  months  in  most  cases  can 
scarcely  be  found.  In  a  very  few  cases  it  may  remain,  small  but 
palpable,  with  some  shortening  of  the  muscle,  and  have  a  permanent 
effect  on  the  position  of  the  head,  producing  a  degree  of  wry-neck. 
Most  cases  need  no  treatment  beyond  gentle  massage  after  the 
tenderness  has  passed  away,  and  stretching  the  muscle  by  move- 
ments of  the  head  toward  the  opposite  side. 

RHEUMATIC  MYOSITIS 

This  disease  occurs  in  children,  either  with  or  without  any 
history  of  strain  or  exposure  to  cold  or  wet,  or  of  rheumatic  symp- 
toms in  any  other  part.  The  pathology  of  the  trouble  is  not  alto- 
gether settled.  It  may  be  considered  hardly  a  surgical  disease,  yet 
it  continually  presents  for  diagnosis  from  injuries  and  wry-neck, 
caries  of  the  cervical  spine,  reflex  spasm  from  throat  inflammation, 
irritations  of  the  spinal  accessory  nerve,  abscesses,  et  cetera.  So- 
called  rheumatic  myositis  comes  on  acutely,  sometimes  after  expo- 
sure to  cold,  with  pain  and  soreness  in  the  muscles  at  the  side  of  the 
neck,  worse  on  movement,  even  to  excruciating  pain  from  the 
slightest  attempt  to  turn  the  head.  It  may  continue  for  several 
days  or  a  week  or  more,  gradually  subsiding.  It  is  relieved  by 
fixation  of  the  head  to  put  the  muscles  at  rest ;  by  rest  in  bed,  which 
partially  does  so;  by  dry  heat;  more  promptly  by  the  use  of  the 
Paquelin  cautery  in  a  small  patch  over  the  affected  area;  by  the 
static  spark ;  sometimes  by  gentle  massage,  anti-rheumatic  medica- 
tion, and  quinine. 

OTHER    FORMS    OF    WRY-NECK    (TORTICOLLIS) 

Wry-neck  may  be  associated  with  hematoma  of  the  sterno- 
mastoid, rheumatic  myositis,  caries  of  the  cervical  spine  (see  Sec- 
tions on  those  topics)  ;  or  caused  by  a  congenital  shortness  of  the 
sternomastoid  muscle,  and  often  with  it  malformation  of  the 
cervical   spine;  by   acquired   contraction   of  the   sternomastoid   or 


i62  SURGICAL   DISEASES    OF   CHILDREN 

the  trapezius  or  the  splenius  muscles  and  perhaps  the  fascise  of  one 
side  of  the  neck;  and  by  muscular  spasm  through  reflex  irritation 
of  nerves  resulting  from  inflamed  glands,  or  the  like. 

In  all  cases  excepting  those  associated  with  cervical  caries,  the 
head  is  abducted  on  the  affected  side  and  rotated  so  that  the  chin 
points  in  the  opposite  direction.  This  position  may  be  constant,  or 
in  some  reflex  and  spasmodic  cases,  intermittent. 

Treatment. — In  all  secondary  and  reflex  cases  the  primary 
cause  should  be  treated.  In  the  chronic  cases,  massage,  stretching 
of  the  contracted  tissues  by  gymnastics,  head  suspension,  carrying 
weights  in  the  hand  of  the  affected  side  while  the  head  is  held 
erect,  are  among  the  methods  of  treatment.  Corrective  apparatus 
may  be  worn.  This  may  consist  of  a  belt  around  the  thorax  and 
another  around  the  head,  the  two  being  connected  by  an  artificial 
muscle  of  rubber  or  coiled  spring  attached  upon  the  sound  side  so 
as  to  draw  the  head  over;  or  it  may  be  in  the  form  of  a  jacket  with 
head  support  under  chin  and  occiput,  such  as  is  used  for  cervical 
and  high  dorsal  caries ;  or  it  may  be  a  leather  or  felt  collar  resting 
upon  the  shoulders  and  holding  the  head  in  position  approximating 
the  normal.  If  the  condition  does  not  yield  to  a  fair  trial  for  a  few 
months  of  these  means,  the  unyielding  tissues  must  be  divided. 
Most  often  the  sterno-mastoid  is  at  fault.  Its  tendons  may  be  cut, 
near  their  clavicular  and  sternal  attachments,  by  either  subcuta- 
neous or  open  tenotomy.  The  latter  is  preferable.  The  head  is  then 
maintained  in  corrected  or  over-corrected  position  by  rest  in  bed 
with  sand  bags  to  the  head,  by  fixation  apparatus,  usually  a  gypsum 
jacket  extended  to  the  head,  until  healing  is  complete.  Apparatus 
may  be,  but  frequently  is  not,  longer  necessary. 

PRIMARY    PROGRESSIVE    MYOPATHY 

PSEUDO-HYPERTROPHIC         MuSCULAR         PARALYSIS         (MuSCUlar 

Pseudo-hypertrophy ;  Lipomatous  Muscular  Atrophy)  is  very  often 
described  with  diseases  of  the  nervous  system.  But  all  that  is  yet 
known  of  its  pathology  would  place  it  among  the  myopathies,  an 
idiopathic  atrophy. 

Etiology. — Nothing  is  known  intimately  of  the  causation  of  this 
disease.  There  is  often  a  history  of  heredity,  the  disease  being 
usually  transmitted  to  the  males  by  the  female  line.  Yet  there  are 
cases  not  hereditary,  and  families  in  which  girls  also  are  affected. 
The  disease  may  first  be  noticed  when  the  infant  should  begin  to 
learn  to  walk,  or  in  childhood,  or  in  youth,  usually  before  the  ninth 
year,  possibly  notjimtil  puberty. 

Pathology. — The  post-mortem  findings  are  all  in  the  muscles. 
Connective  tissue  is  increased,  while  muscle  tissue  has  been  replaced 
by    fat.      The    muscles    which    were    at    first    hypertrophied    have 


MUSCLES,   TENDONS    AND    CELLULAR    TISSUES  163 

shrunken  as  the  disease  advanced.  So  extensively  has  the  change 
taken  place  that  the  muscles  present  to  the  naked  eye  a  yellow  color 
as  though  composed  entirely  of  fat.  The  microscope  may  find  re- 
mains of  muscle  fibers  and  be  able  to  detect  in  part  their  striation. 
The  remaining  fibers  vary  greatly  in  their  diameter,  and  this  varia- 
tion is  very  irregular,  narrow  and  wider  fibers  being  intermingled 
in  the  same  muscle.  There  are  no  changes  found  in  the  brain  or 
spinal  cord,  nor  yet  in  the  nerves. 

Pathologists  have  not  agreed  as  to  the  nature  of  the  disease. 
Some  consider  it  essentially  an  inflammation  resembling  many  inter- 
stitial inflammations  in  which  there  is  a  resulting  increase  of  con- 
nective tissue  with  degeneration  or  atrophy  of  the  other  cell 
elements.  Others  consider  it  an  expression  of  faulty  development 
by  overgrowth  of  connective  tissue  at  the  expense  of  the  muscle 
tissue. 

Symptoms  and  Diagnosis. — Slowness  in  learning  to  walk,  or 
in  older  children  weakness  in  walking  or  in  going  upstairs,  are 
early  symptoms.  This  condition  may  continue  for  weeks  without 
additional  symptoms.  In  fact,  the  whole  course  of  the  disease  is 
chronic,  all  the  changes  coming  very  gradually  and  persisting  for 
months  and  years.  With  the  appearance  of  weakness  or  after  it  may 
be  noticed  that  some  of  the  muscles  are  enlarging,  especially  those 
that  seemed  weakest.  The  muscle  changes  are  bilateral.  The 
muscles  of  the  calves  are  most  frequently  and  most  markedly  af- 
fected, sometimes  those  of  the  gluteal  region  or  of  the  thighs.  The 
spinati,  dnfra-  and  supra-,  are  next  in  order,  and  the  deltoid.  The 
pectoral  muscles  and  the  latissimus  dorsi  are  not  usually  enlarged, 
though  often  wasted  (see  Figs.  2,7  and  147)  ;  but  cases  have  been 
reported  in  which  the  latissimus  dorsi  also  were  enlarged;  also  the 
biceps,  triceps,  and  sterno-mastoid.  It  is  said  that  the  pectorals 
are  the  only  muscles,  not  even  excepting  the  heart,  that  have  never 
been  found  enlarged.  The  muscular  hypertrophy  is  gradually  suc- 
ceeded by  a  process  of  atrophy,  beginning  in  the  upper  extremities 
and  leaving  the  calves  until  the  last.  In  some  cases  the  atrophy  of 
certain  muscles  is  present  from  the  first  and  goes  on  simultaneously 
with  the  hypertrophy  of  those  before  mentioned.  The  atrophy 
usually  begins  in  the  pectorals,  and  successively  affects  the  latissi- 
mus dorsi,  the  trapezius,  the  serratus  magnus,  the  extensors  of  the 
back,  and  the  thigh  muscles.  Finally  every  voluntary  muscle  in 
the  body  may  undergo  atrophy  although  the  muscles  of  the  hand 
are  generally  spared. 

The  appearance,  attitude,  and  movements  of  a  well-developed 
case  are  very  peculiar  and  characteristic,  being  especially  marked 
in  those  cases  in  which  atrophy  of  some  muscles  is  present  with 
hypertrophy  of  others.    The  patient  stands  very  insecurely,  with  his 


164 


SURGICAL   DISEASES    OF    CHILDREN 


feet  wide  apart,  his  abdomen  projecting  forward,  his  spine  in  lordo- 
sis, his  shoulders  thrown  far  backward.     In  walking  he  brings  his 

center  of  gravity  over 
one  thigh,  swings  the 
other  limb  forward, 
then  sways  the  body 
over  the  other  thigh, 
and  repeats  the  move- 
ment. The  movements 
of  rising  from  the  hori- 
zontal to  the  erect  posi- 
tion are  most  peculiar 
and  pathognomonic.  Ow- 
ing to  the  weakness  of 
the  extensors  of  the 
leg,  the  patient  is  un- 
able to  raise  his  whole 
weight  by  extending  the 
lower  extremities.  On 
account  of  the  weakness 
of  the  extensors  of  the 
back  he  cannot  raise  the 
trunk  by  them  alone.  He 
divides  the  weight  be- 
tween the  extremities  by 
getting  upon  "  all  fours," 
hands  and  knees  first, 
then  raises  the  hind 
quarters  by  extending 
the  legs.  Then  to  raise 
the  trunk  he  brings  the 
hands  to  the  ankles  and 
by  grasping  them  and 
alternately  raising  the 
hands  and  grasping  the 
lower  extremities  a  lit- 
tle higher  and  higher, 
he  straightens  up. 
Different  cases  will  pre- 
sent variations  in  movements  according  to  the  involvement  of 
various  muscles.  As  the  disease  advances  the  patient  will  not  be  able 
to  stand,  rise,  nor  even  to  stand  when  placed  upon  his  feet.  In  ad- 
vanced cases  there  are  deformities  as  a  result  of  the  immovable  con- 
traction of  muscles.  One  of  the  commonest  is  that  the  ankles  are 
flexed,   holding  the    foot   in   a   position   of   talipes   equinus.     The 


MUSCULAR 

a    boy    of 


Fig.  z7-  Pseudohypertrophic 
PARALYSIS,  well  developed  in 
12  years.  Note  enlargement  of  muscles 
of  the  calves,  the  gluteal  regions,  and  of 
the  infra-spinati,  and  the  wasting  of  the 
deltoid  and  latissimus  dorsi.  Boy  cannot 
stand  nor  even  rise  to  the  sitting  posture. 


MUSCLES,    TENDONS    AND    CELLULAR    TISSUES  165 

knees  are  apt  to  be  bent,  fixing  the  legs  at  a  right  angle  with  the 
thighs.     The  biceps  may  keep  the  forearm  rigidly  flexed. 

Accompanying  symptoms  are  occasionally  reported,  such  as 
optic  neuritis  with  atrophy  of  the  disc,  myotonia  congenita,  and 
epilepsy.  Also  cranial  asymmetry.  But  there  is  no  constant  con- 
nection between  these  conditions  and  the  disease  in  question.  More 
usual  accompaniments  are  mental  weakness  or  slowness,  and  im- 
perfections of  speech.  It  is  sometimes  difficult  to  tell  whether  the 
speech  difficulty  is  from  a  central  cause  or  from  implication  of  the 
muscles  of  the  tongue. 

The  tendon  reflexes  are  but  slightly  affected  at  first,  but  grad- 
ually disappear  as  the  disease  advances.  Likewise  the  electrical 
reactions,  both  galvanic  and  faradic,  are  found  normal  at  first,  but 
lessen  with  the  progress  of  the  case.  However,  they  never  exhibit 
at  any  stage  the  reaction  of  degeneration.  There  are  no  fibrillary 
twitchings  and  no  disturbance  of  sensation.  Mechanical  irrita- 
bility is  lessened. 

In  this  almost  helpless  state  patients  linger  for  years,  increas- 
ing in  weakness  with  the  atrophy  of  muscle  tissue,  and  increasing 
in  deformity.  The  disease  may  progress  more  slowly  if  puberty  is 
reached.     Few,  if  any,  ever  reach  adult  life. 

Prognosis  and  Treatment. — The  prognosis  is  invariably  hope- 
less. Electricity,  has  been  recommended  to  possibly  arrest  the  dis- 
ease, but  the  results  scarcely  justify  the  claim.  Massage  may  some- 
what modify  the  rigidity  of  the  contractions,  and  gymnastics  will 
aid  to  retain  some  use  of  the  disabled  muscular  system.  Tenotomies 
(followed  by  plaster  casts)  may  be  done  if  contraction  deformities 
interfere  with  the  comfort  or  the  care  of  the  patient,  or  if  a  degree 
of  usefulness  of  the  limbs  will  be  prolonged  thereby.  , 

The  Juvenile  Type  and  the  Peroneal  Type. — There  are 
two  other  forms  of  primary  muscular  atrophy,  which  are  so  similar 
to  each  other  and  to  pseudo-hypertrophic  muscular  paralysis,  that 
it  is  not  definitely  settled  whether  they  may  not  be  only  variations 
of  the  same  disease. 

The  juvenile  type  or  "  Erb's  juvenile  form,"  sometimes  called 
the  scapulo  humeral  type,  may  also  be  hereditary.  It  begins  in 
childhood  or  youth,  not  congenitally  or  dn  infancy.  The  atrophy  is 
limited  to  the  muscles  of  the  shoulder  and  upper  arm,  the  gluteal 
region  and  the  thigh.  The  muscles  of  the  legs  and  feet,  hands  and 
forearms,  remain  unaffected  or  slightly  hypertrophied.  Thus  the 
distribution  of  the  paralysis  is  different  from  that  of  pseudo- 
hypertrophic, and  also  there  is  generally  no  marked  hypertrophy. 
There  is  no  reaction  of  degeneration,  and  no  fibrillary  twitching. 
The  knee-jerks  are  absent  or  diminished. 

Facial  Scapulo-humeral  Type. — There  has  been  described, 


i66  SURGICAL   DISEASES    OF   CHILDREN 

notably  by  Landouzy  and  Dejerine,  what  appears  to  be  a  subvariety 
of  the  scapulo-humeral  type,  also  called  "  progressive  muscular 
paralysis  of  childhood  "  (Duchenne),  and  also  as  the  infantile  facial 
type.  In  this  the  phenomena  are  the  same  as  those  presented  in 
Erb's  juvenile  form,  with  the  addition  that  the  muscles  of  the  face 
are  affected.  The  effect  of  the  disease  upon  the  orbicularis  oris  is 
to  allow  the  mouth  to  remain  always  open.  As  the  lips  are  thick- 
ened, and  all  the  remaining  muscles  of  the  face,  excepting  the  leva- 
tors of  the  angles  of  the  mouth,  are  atrophied,  there  is  a  peculiar 
pouting  expression  which  is  called  the  "  tapir  mouth." 

Peroneal  Type. — In  this  form  of  progressive  muscular 
atrophy  the  wasting  begins  in  the  extensor  longus  hallucis,  then  the 
extensor  communis  digitorum  and  the  peroneal  group.  The  small 
muscles  of  the  foot  are  next  affected,  and  some  think  the  small 
muscles  even  precede  the  extensors  and  peroneals  in  the  atrophic 
process.  Some  time,  perhaps  years  later,  the  calf,  and  especially 
the  thigh  muscles,  beginning  with  the  vastus  internus,  waste  in  a 
similar  manner.  After  a  pause  of  several  years  atrophy  begins  in 
the  muscles  of  the  hand,  and  then  in  the  extensors  of  the  forearm. 
Later  the  pronators  and  supinators  of  the  forearm  are  attacked. 
The  supinator  longus,  the  muscles  of  the  arm,  shoulder,  neck,  face 
and  body,  remain  unaffected.  This  disease  is  like  the  preceding 
myopathies  in  that  a  hereditary  influence  is  apparent,  and  that  more 
boys  than  girls  are  afflicted.  Its  chronic  course,  its  paralysis  and 
its  resulting  contractions  are  also  similar.  It  differs  not  only  in  the 
succession  of  the  muscles  attacked  and  in  their  grouping,  but  in 
the  fact  that  the  reaction  of  degeneration  and  also  in  most  cases 
fibrillary  twitchings  are  present.  Authorities  differ  widely  in  their 
opinions  on  the  true  etiology  of  the  peroneal  form.  There  seems 
to  be  a  considerable  weight  of  evidence  that  it  is  due  to  changes  in 
the  ganglion  cells  of  the  anterior  horns  of  the  lumbar  cord.  Some 
hold  it  probable  that  the  type  is  not  constant  and  that  there  are 
here  grouped  cases  due  to  various  causes,  myopathic,  neuropathic, 
myelopathic.  Medical  treatment  is  unavailing.  Surgical  treatment 
consists  in  operations  upon  tendons  for  the  relief  of  contractions 
and  the  application  of  splints  and  braces,  as  will  be  described  in 
the  sections  on  tendons,  infantile  paralysis,  and  the  lower  ex- 
tremities. 

TENDONS  AND  THEIR  SHEATHS 

Tendons  and  their  sheaths  in  children  are  doubtless  subject  to 
all  the  ills  that  afflict  similar  structures  in  older  persons,  although 
gonorrheal  and  gouty  teno-synovitis  must  be  very  rare.  But  there 
are  two  inflammatory  states  that  are  common  enough  to  require 
special  mention,  namely,  acute  teno-synovitis  and  acute  purulent 
teno-synovitis, 


MUSCLES,   TENDONS    AND    CELLULAR    TISSUES  167 

Acute  Teno-synovitis  is  caused  by  over-use  of  the  tendons, 
especially  with  subsequent  exposure  to  cold,  and  in  rheumatic  sub- 
jects. One  has  seen  it  follow  excessive  piano  practice,  the  game 
of  tennis,  and  the  like.  A  common  seat  is  the  extensor  and  supi- 
nator tendons  of  the  forearm,  especially  those  of  the  thumb,  and 
the  tendo  Achillis. 

Syiuptoms. — The  symptoms  are  more  or  less  swelling  over  the 
course  of  the  tendon,  with  tenderness  on  pressure,  moderate  pain 
when  the  part  is  at  rest,  but  more  severe  pain  when  the  tendon  is 
put  into  action.  On  moving  the  tendon  there  is  a  "  rub  "  or  very 
fine  crepitus  noticeable.  There  is  considerable  lameness  or  stiffness 
after  rest,  which  wears  off  somewhat  during  exercise  to  return  again 
during  rest.  The  inflammation  produces  a  fibrinous  exudate  upon 
the  inner  surface  of  the  sheath,  which  gives  rise  to  the  friction,  dry 
at  first,  but  there  may  be  a  considerable  serous  effusion. 

Treatment. — Treatment  consists  in  rest,  often  best  maintained- 
by  a  light  splint  applied  outside  of  a  wet  towel.  Hot  or  cold  water 
may  be  used  as  seems  most  grateful,  usually  cool  water  when  the 
part  feels  hot,  and  hot  compresses  and  douches  later.  Liniments 
of  belladonna,  iodine,  chloroform,  or  soap  may  be  used. 

Acute  Purulent  Teno-synovitis. — This  may  take  place  in 
any  tendon  sheath.  The  same  facts  concerning  the  disease  and  the 
same  principles  of  treatment  are  applicable  wherever  the  trouble 
is  located.  But  it  is  so  common  in  the  hand,  and  so  many  hands 
have  been  impaired  or  even  ruined  for  life  by  it,  that  by  describing 
purulent  teno-synovitis  in  this  member  attention  will  be  directed  to 
the  importance  of  what  at  first  seems  a  small  matter.  Infection  may 
gain  entrance  by  way  of  the  blood,  but  very  often  it  results  from  a 
wound,  a  crush,  or  more  superficial  infection  in  proximity  to  the 
sheath.  Having  set  up  an  inflammation  in  the  sheath,  there  is  pain, 
swelling  and  tenderness  locally  in  its  course,  and  the  usual  con- 
stitutional symptoms  of  sepsis.  Instinctively  the  finger  or  the  whole 
hand  is  held  in  the  position  of  semi-flexion  in  order  to  relax  tension 
upon  the  tendons  and  within  the  sheath. 

The  inflammation  may  extend  from  one  separate  tendon  sheath 
to  another  by  involvement  of  the  intervening  tissues ;  but  it  will 
spread  far  more  certainly  and  rapidly  along  a  continuous  sheath. 
Reference  to  Fig.  38  will  be  a  reminder  of  the  usual  arrangement 
of  the  sheaths  of  the  flexor  tendons  in  the  hand  and  forearm.  The 
sheaths  of  the  index,  middle  and  ring  fingers  end  near  the  meta- 
carpo-phalangeal  joint;  but  those  of  the  thumb  and  little  finger 
extend  into  the  palm  and  wrist.  Therefore,  infectious  inflamma- 
tions of  the  sheaths  of  the  thumb  and  little  finger  are  especially 
dangerous.  When  infection  gains  entrance  to  a  tendon-sheath  its 
walls    become    infiltrated,    pus    accumulates.      The    tendon    itself 


168 


SURGICAL   DISEASES    OF   CHILDREN 


becomes  infiltrated  and  edematous,  its  inter-fascicular  tissue  suppur- 
ates and  separates  its  fibers.     The  tendon  and  the  sheath  may  be 


Fig.  38.  Usual  arrangement  of  the  sheaths  of  the  flexor  tendons  of 
THE  hand  and  forearm.  The  sheaths  of  the  index,  middle  and  ring 
fingers  end  near  the  metacarpophalangeal  joint;  but  those  of  the  thumb 
and  little  finger  extend  into  the  palm  and  wrist,  thus  increasing  the 
danger  of  extension  of  infectious  inflammation  in  these  sheaths.  The 
stippled  areas  show  the  sheaths.  The  wavy  lines' indicate  the  position 
of  the  vessels  and  with  them  are  the  nerves.  The  straight,  heavy  lines 
show  where  incisions  can  be  made  safely  and  to  the  best  advantage  for 
drainage. 

destroyed  if  left  until  the  pus  finds  exit  spontaneously  by  bursting- 
through  the  sloughing  tissues.  If  the  infection  gets  into  the  palm 
and  wrist  it  may  not  even  stop  there  but  extend  into  the  forearm. 


MUSCLES,   TENDONS   AND    CELLULAR   TISSUES 


169 


Treatment, — As  soon  as  the  diagnosis  can  be  made,  the  affected 
sheaths  should  be  opened  freely.  In  Fig.  38  the  double  wavy  lines 
indicate  approximately  the  position  of  the  vessels  and  nerves,  and 
the  heavy  straight  lines  show  where  incisions  can  be  made  safely  and 
to  the  best  advantage  for  drainage.  It  is  not  enough  that  an  open- 
ing is  made  into  the  inflamed  sheath ;  the  opening  should  be  through- 
out its  entire  extent.  The  hand  should  then  be  soaked  in  a  bath 
of  mercuric  bichloride  1-2000,  or  other  antiseptic,  and  dressed  with 
a  hot,  wet  antiseptic  gauze  compress  surrounded  by  oil-silk  and  a 
bandage,  and  supported  on  a 
splint.  If  it  be  the  thumb  or 
the  little  finger  that  is  infected, 
or  if  it  be  in  one  of  the  first 
three  fingers  and  the  case  is  far 
advanced,  the  attention  should 
not  be  limited  to  the  phalanges; 
the  palm  of  the  hand  and  wrist 
should  also  be  carefully  ex- 
plored and  if  infected  should  be 
at  once  opened  and  drained.  It 
is  necessary  to  drain  the  entire 
infected  area,  even  if  the  open- 
ings must  go  into  the  forearm. 
This  would  only  occur  in  neg- 
lected cases  or  in  cases  timidly 
treated,  which  is  the  same  thing. 
If  the  infection  has  extended 
through  the  palm  and  the  back 
of  the  hand  is  swollen  and 
boggy,  it  must  be  incised,  and 
a  rubber  drainage  tube  passed 
through.  If  the  abscess  is  deep  in  the  palm,  rubber  drainage  will 
be  necessary,  and  will  allow  of  irrigation  till  the  discharge  lessens, 
when  cigarette  drains  of  rolled  rubber  tissue  may  be  substituted  and 
are  less  likely  to  press  unduly.  Even  when  abscess  is  evacuated  be- 
fore the  tendon  has  suffered  severely  and  the  best  treatment  is  fol- 
lowed, the  result  will  show  adhesions  of  tendons  and  sheaths,  scar  tis- 
sue and  contractions,  which  will  appear  disappointing  to  the  patient 
and  his  family.  However,  there  will  be  great  improvement  with  use 
of  massage  and  passive  movements  persistently  carried  out,  and  the 
result  will  be  infinitely  better  than  if  a  Fabian  plan  of  treatment  had 
been  followed.  Somewhat  recently  the  Bier-Klapp  method  of  in- 
ducing passive  hyperemia  has  been  applied  with  good  results  in 
these  inflammations  of  infectious  origin.  (See  also  Sections  on 
Septicemia  and  The  Treatment  of  Arthritis.)  The  hyperemia  is 
induced  either  by  constriction  of  the  limb  above  the  inflammation 


Fig. 


39.     Hibbs-Sporon   method  of 
tendon   lengthening. 


170 


SURGICAL   DISEASES    OF    CHILDREN 


or  by  cupping.  Hyperemia  is  carried  only  to  the  point  of  redness 
or  slight  bluish  redness,  never  causing  either  blueness,  pain,  cold- 
ness, nor  numbness.  Constriction  for  an  hour,  or  suction  for  five 
minutes  followed  by  rest  for  three  minutes  during  twenty  to  forty- 
five  minutes  once  or  twice  a  day,  is  regarded  as  sufficient.  If  pus 
is  present  or  edema  threatens  necrosis,  incision  or  punctures  should 
precede  the  constriction  or  suction  treatment. 


RHEUMATIC  TENDINOUS  NODULES 

In  the  hospitals  and  dispensaries  of  England,  Scotland,  and 
Ireland,  one's  attention  was  frequently 
drawn  to  small  nodules  in  the  line  of  the 
extensor  tendons  of  the  fingers  or  hands 
or  about  the  insertion  of  the  triceps  at  the 
elbow.  They  could  also  be  found  upon 
the  spinous  processes  of  the  vertebrse, 
upon  the  patella,  and  the  subcutaneous 
tendons  near  the  maleoli.  The  nodules 
vary  in  size  from  a  pin's  head  to  a  split 
pea  or  even  larger,  and  are  quite  hard. 
They  are  most  easily  seen  upon  the  backs 
of  the  hands  and  the  spinous  processes 
and  at  the  maleoli  in  a  thin  child„  They 
are  said  to  be  composed  of  fibrous  tissue, 
and  considered  a  manifestation  of  the 
rheumatic  condition,  coming  and  going  at 
intervals  in  company  with  other  rheu- 
matic symptoms.  The  nodules  are  usually 
in  numbers  and  remain  for  weeks  or 
months  and  disappear  spontaneously  or 
perhaps  as  a  result  of  anti-rheumatic 
treatment. 


Fig.    40.      A  N  D  E  R  s  0  n's 

METHOD  OF  TENDON 
LENGTHENING,        showing 

the  line  of  the  incision 
and  the  extent  to  which 
the  ends  may  be  sepa- 
rated before  they  are 
sutured    together. 


INJURIES  OF  TENDONS  AND  THEIR 
SHEATHS 


Injuries  of  tendons  and  their  sheaths 
are   common  and   should   always   receive 
careful    attention.      Spontaneous    rupture 
is  rare  if  it  ever  occurs  in  children.     Di- 
vision by  accidental   injuries   are  frequently  met.      Such  injuries 
should  always  be  immediately  repaired,  the  severed  ends  of  ten- 
dons  united,   and,   if   practicable,   their   sheaths   neatly    closed,    all 
under    the    strictest    antiseptic    precautions.      The    dangers   of   in- 


!> 


MUSCLES,   TENDONS   AND    CELLULAR   TISSUES  171 

fection  of  tendons  and  their  sheaths  is  very  great.  (See  Section 
on  Purulent  Teno-synovitis.)  The  repair  of  injured  tendons  is 
conducted  upon  the  same  principles  as  apply  in  operations  of 
election  upon  tendons.  These  are  so  frequently  necessary  in  the 
correction  of  deformities  that  we  will  now  consider  the  subject 
in  a  general  way. 

OPERATIONS  UPON  TENDONS 

Tendon  Lengthening. — It  is  necessary  to  lengthen  tendons 
when  from  congenital  deformity,  or  injury,  or  such  diseases  as 
paralysis,  spastic  paralysis,  or  contractions  resulting  from  chronic 
joint  diseases,  they  are  too  short  to  allow  a  natural  position  or  func- 
tion of  the  parts.  Also  in  the  operation  of 
transplanting  when  a  tendon  is  not  long 
enough  to  reach  the  point  of  implantation. 
A  tendon  may  be  lengthened  by  simple  sec- 
tion within  its  sheath — linear  tenotomy. 
Lengthening  results  by  separation  of  the 
divided  ends  and  the  organization  of  the 
blood-clot  which  fills  the  gap  between  them. 
This  new  portion  will  be  mainly  composed 
of  scar  tissue  and  a  few  fibrils  of  tendon 
tissue,  and  answers  the  purpose  of  the  ten- 
don. This  fibrous  tissue  in  some  instances 
will  undergo  a  degree  of  stretching;  and 
yet  this  method  of  lengthening  has  yielded 
satisfactory  results  in  thousands  of  in- 
stances. Tenotomy  can  be  done  by  two 
methods,  the  subcutaneous  and  the  open.  In 
either  method  strict  antisepsis  is  imperative. 

Subcutaneous  Tenotomy. — Small,  narrow-bladed  tenotomes  are 
necessary  for  this  operation.  They  are  either  sharp  or  blunt 
pointed,  and  straight,  bellied,  or  concave  upon  the  cutting  edge. 
No  Esmarch  is  used.  The  left  index  finger  or  thumb  of  the  surgeon 
touches  the  tendon  and  tests  its  tension  which  should  be  only  mode- 
rately firm.  The  sharp-pointed  tenotome  held  flat  is  inserted  at  one 
side  of  the  tendon  to  be  cut,  the  sheath  of  the  tendon  is  pierced, 
and  the  blade  thrust  either  above  or  below  it  at  the  choice  of  the 
operator.  The  edge  of  the  knife  is  then  turned  toward  the  tendon 
and  the  latter  is  cut  through  with  a  careful  sawing  movement.  The 
left  hand  as  well  as  the  knife-hand  feels  the  yielding  of  the  tendon. 
The  knife  is  withdrawn  at  the  small  wound  of  entrance.  The 
tendon  should  not  be  put  too  much  upon  the  stretch  as  the  cut  is 
finished.  Some  operators  prefer  after  piercing  the  sheath  with  the 
sharp  tenotome  to  withdraw  it  and  insert  the  round-pointed  blade 


< 


r 


Fig,      41.      PoNCET^s 

METHOD     OF     TENDON 
LENGTHENING. 


172 


SURGICAL  DISEASES    OF   CHILDREN 


as  being  less  likely  to  injure  a  vessel  or  nerve  or  to  pierce  the  skin 
after  severing  the  tendon.  Some  prefer  to  cut  downward  through 
the  tendon,  and  some  to  insert  the  blade  beneath  the  tendon  and  cut 
outward.  The  latter  is  probably  the  safer  way  when  there  are 
vessels  and  nerves  in  proximity.  The  wound 
is  immediately  covered  with  a  small  pad 
of  iodoform  gauze  and  a  bandage,  and  a  fixed 
dressing,  usually  plaster  of  Paris,  is  applied. 
The  advantages  of  the  subcutaneous 
method  are  that  the  small  wound  gives  lit- 
tle chance  for  infection,  and  there  is 
scarcely  any  scar  to  look  unsightly,  or,  what 
is  more  important,  to  contract,  to  chafe,  be- 
come painful  or  break  down  under  pressure. 
The  disadvantages  are,  the  possibility  of  in- 
jury to  a  vessel  or  nerve,  or  other  sur- 
rounding structure,  or  of  not  making  a 
smooth  and  complete  cut  of  the  entire  ten- 
don. (17) 

The  Open  Method. — If  operating  upon  an 
extremity  the  Esmarch  bandage  is  usually, 
though  not  invariably,  employed.  By  this 
method  an  incision  is  made  parallel  to  and 
a  little  to  one  side  of  the  tendon.  The 
sheath  is  opened  and  the  tendon  being  ex- 
posed to  sight  by  sharp  and  blunt  dissection, 
is  divided.  If  the  tendon  cannot  be  isolated, 
or  it  is  not  desirable  to  dissect  under  it,  the 
wound  should  be  retracted  so  as  to  expose 
it  plainly  to  view.  It  can  then  be  divided 
carefully  by  small  cuts  with  the  knife.  The 
tendon  sheaths  and  the  skin  wounds  are  each 
closed  with  sutures.  The  advantages  of  the 
open  operation  are  that  it  is  all  under  the 
guidance  of  the  eye,  which  is  safer,  especially 
in  certain  situations. 

The  disadvantages  are,  that  with  the  larger 
wound  there  is  greater  opportunity  for  sep- 
a  n  d  sis  and  a  larger  amount  of  scar  tissue. 
Prac-       Many  other  methods  of  tendon  lengthen- 


FiG.    42.    Method    of 

INTRODUCING  STRONG  SILK 
TO  ACT  AS  A  TENDON  FOR 
PERIOSTEAL  IMPLANTA- 

TION,   in  tendon    length 
ening. — B  r  y  a  n  t 
Buck's    American 

tice  of  Surgery.  .         ,  ,  ,      .      ,  ,  .      ,         .  , 

mg  have  been  devised  and  practiced,  with 

the  object  of  retaining  tendon  tissue  throughout  the  length- 
ened portion,  and  obviating  scar  tissue.  They  are  performed 
through  an  open  wound.  Most  of  them  require  suture  of 
the   split   or  partly   divided   tendon.      The    Hibbs-Sporon   method 


MUSCLES,   TENDONS    AND    CELLULAR   TISSUES  173 

has  the  advantage  of  requiring  no  suture.  (See  Fig.  39.) 
Through  an  open  incision  the  tendon  is  isolated,  raised  upon  two 
blunt  dissectors  and  split  with  a  narrow-bladed  knife  as  shown  in 
the  diagram.  By  the  Anderson  method  the  tendon  is  split,  slid  and 
ready  to  be  sutured,  as  shown  in  Fig.  40.  This  is  one  of  the  sim- 
plest and  best  methods.  Fig.  41  shows  Poncet's  method — by 
nicking  the  sides  of  the  tendon.  It  allows  considerable  lengthening, 
but  has  a  great  many  points  for  subsequent  adhesion  to  the  sheath. 
There  are  many  other  methods  of  lengthening  by  splitting  and  splic- 
ing. There  is  a  method  of  augmenting  the  length  of  a  tendon  by 
introducing  a  cord  of  siilk  or  chromacized  catgut,  to  reach  from 
the  end  of  the  short  tendon  to  the  desired  point  of  attachment. 
This  graft,  as  it  is  called,  constitutes  a  kind  of  "  false  work  "  upon 
which  a  bridge  of  tendinous  and  fibrous  tissue  is  constructed  by 
the  reparative  processes  of  nature.  The  silk  or  catgut  finally  dis- 
appears or  is  cast  off.    Fig.  42  shows  this  method. 

Tendon  Shortening  is  indicated  in  the  relaxation  which  re- 
sults from  paralysis,  or  a  somewhat  similar  condition  from  disuse, 
as  in  joint  disease  and  the  like;  or  overstretching  of  tendons  from 
spastic  contractures  of  antagonistic  muscles ;  or  in  flail-joint,  where 
all  the  tendons  about  the  joint  are  relaxed;  or  in  tendons  over- 
stretched from  injury;  or  to  fit  the  requirements  of  the  case  in  ten- 
don transplantation.  Tendons  may  be  shortened  without  sacrificing 
tendon  tissue  by  simply  puckering  with  a  drawstring,  or  by  looping 
and  suturing ;  or  by  removing  only  a  part  of  the  thickness  of  the 
tendon  and  then  looping  and  suturing;  or  by  splitting  the  tendon 
and  then  looping  each  half  separately  and  suturing,  as  seen  in  dia- 
grams in  Figs.  43  and  44. 

Tendon  Transplantation  may  be  employed  when  the  func- 
tion of  a  muscle  has  been  lost,  usually  through  paralysis  in  some 
form,  or  when  one  muscle  or  group  of  muscles  has  been  overpow- 
ered by  another  muscle  or  muscle  group.  Poliomyelitis  presents  fre- 
quent cases.  Meningitis  and  hemiplegia  are  much  less  frequent  con- 
tributors. If  ample  muscular  power  is  within  reach  and  can  be 
spared,  or  a  part  of  it  can  be  spared,  from  its  normal  situation,  ten- 
don transplantation  may  transfer  it  to  the  point  of  need.  Accident 
may  destroy  muscle  or  tendon  beyond  repair  and  leave  a  condition 
remediable  by  transplantation.  Deformity  of  joints  from  chronic 
inflammations  with  flexion  contractions  have  afforded  opportunities 
for  tendon  transference.  Also  the  over-stretching  of  tendons  in 
congenital  club-foot ;  in  syringomyelia  and  in  other  more  rare  con- 
ditions. Some  advise  strongly  against  transplantation  in  case  of 
only  partial  paralysis,  considering  tendon  lengthening  or  shortening 
or  the  use  of  braces  and  massage  more  likely  to  give  good  results. 
In  no  case  should  transplantation  be  considered  until  all  hope  of 


174 


SURGICAL   DISEASES    OF   CHILDREN 


recovery  without  it  is  past.  Otherwise  the  operation,  even  if  suc- 
cessful for  the  present,  is  not  only  unnecessary  but  positively  harm- 
ful. Transplantation  may  also  be  useful  to  correct  deformity  even 
without  restoring-  function,  for  instance,  when  joint  disease  has 
resulted  in  contracture  of  the  flexors  at  the  expense  of  the  exten- 
sors. Every  case  should  be  carefully  studied  to  ascertain  which 
muscles  have  lost  their  function  and  which  can  be  utilized  to  sub- 
stitute them.  There  is  more  danger  of  failure  through  error  in 
judgment  upon  the  selection  of  cases  for  operation  or  the  choice 
of  the  tendons  which  should  be  transplanted  than  through  sepsis 
or  failure  of  union.  This  task  of  precise  examination  of  each  muscle 
and  muscle  group  is  not  easy  of  accomplishment  in  young  children. 


Fig.  43.     Method  of  shortening  tendons  by  looping. 


\) 


11 

u 

Fig.    44.      Three    methods    of    tendon    shortening. — Binnie's    Manual    of 

Operative  Surgery. 

Electrical  tests  are  practically  useless.  Infants  and  children  can- 
not or  will  not  execute  voluntary  movements  at  our  bidding.  We 
must  watch  their  voluntary  movements  or  play  with  them  in  such 
a  way  as  to  elicit  the  movements  which  will  enable  us  to  judge  of 
the  power  of  individual  muscles  and  groups,  and  to  carefully  plan 
the  work  that  is  to  be  undertaken. 

If  there  is  deformity  it  should  be  corrected  if  possible  before 
the  transplantation,  allowing  time  for  recovery  from  the  operation 
of  correction.  But  if  the  correction  of  deformity  necessitates  the 
cutting  of  tendons  that  will  be  used  in  the  transplantation,  the  opera- 
tions of  correction  and  transplantation  may  be  done  at  the  same 
sitting.     (Vulpius.) 


MUSCLES,   TENDONS    AND    CELLULAR    TISSUES 


175 


However,  the  correction  should  take  precedence,  so  that  the 
proper  degree  of  tension  can  be  secured  for  the  transplanted  tendon 
in  its  new  situation.  The  transplanted  tendon  should  be  upon  the 
stretch  when  it  is  fastened  in  its  new  situation. 

The  donating  tendon  should  take  the  shortest  possible  route 
to  the  receiving  tendon  or  point  of  insertion.  This  route  may  often 
be  made  by  tunneling  with  a  grooved  director  or  by  a  blunt  dis- 
sector from  the  incision  which  exposed  the  donating  tendon  to  the 
separate  incision  at  the  point  where  it  is  to  be  united  with  the  re- 


FiG.   45.     Different   methods  of   Tendon   transplantation. — Vulpius. 

ceiving  tendon.  Angles  should  be  avoided.  Sometimes  the  whole 
of  a  donating  tendon  is  not  transplanted,  but  only  a  portion  of  it 
is  split  off  for  that  purpose.  And  if  it  is  not  long  enough  to  reach 
to  the  desired  point,  in  certain  situations  the  muscle  as  well  as  the 
tendon  may  be  split  (by  dry  dissection  in  the  line  of  its  fibers), 
giving  each  portion  of  the  split  tendon  that  portion  of  the  muscle 
which  belongs  to  it. 

Incisions  for  the  purpose  of  exposing  tendons  should  never  be 
made  directly  over  the  tendon,  but  at  one  side  of  it,  and  so  near 
that  the  parts  may  be  slid  over  the  field  of  the  deeper  work.  Flap 
formation  should  be  avoided,  as  it  favors  the  formation  of  cica- 
tricial tissue  and  contractions.  The  incision  in  the  tendon  sheath 
should  not  be  directly  under  the  skin  incision. 

In  splitting  up  tendon  and  muscle,  the  fascia  should  not  be 
divided  near  the  bone,  and  it  is  not  necessary  to  divide  the  fascia 
through  the  entire  length  of  the  skin  incision.     An  interrupted  in- 


176 


SURGICAL   DISEASES    OF    CHILDREN 


cision  can  be  made  in  the  fascia,  through  the  openings  of  which 
the  dissector  can  work.  This  leaves  bridges  of  fascia,  which  aid  in 
adjustment  and  in  union. 

A  normal  muscle  tendon  can  be  transplanted  to  a  paralyzed 
muscle  tendon.  Or  it  can  be  attached  to  bone  (strictly  speaking, 
to  periosteum).  The  sound  tendon  can  be  united  to  the  paralyzed 
without  loosening  the  attachment  of  either,  or  by  cutting  the  para- 
lyzed tendon  and  attaching  it  to  the  sound  tendon ;  or  by  cutting 
both  and  attaching  the  proximal  portion  of  the  sound  tendon  to 
the  distal  portion  of  the  paralyzed  tendon;  or  by  splitting  off  por- 


r  ^     t 

Fig.    46.      DiFFEREXT    WAYS    OF    INTRODUCIXG    SUTURES    IXTO    TENDONS    SO    THAT 

THEY  WILL  NOT  CUT  OUT.     The  arrows   show  the  direction  in  which  the 
thread  should  be  drawn. — Suter,  Archiv.  f.  Klin.  Chir.     1903-4. 

tions  of  one  or  both  tendons  and  uniting  them.  The  diagrams  in 
Fig.  45  illustrate  various  methods  of  transplantation. 

Tendon  Suturing. — All  operations  on  tendons  should  be 
done  under  the  strictest  antiseptic  rules,  and  all  open  operations 
with  the  Esmarch  constrictor.  Round  needles  are  better  for  ten- 
don sutures,  though  any  shape  may  be  used.  Any  of  the  usual 
suture  materials  can  be  used,  but  silk  and  chromicized  catgut  are 
most  frequently  chosen. 

As  tendons  are  easily  split  longitudinally  by  division  of  their 
component  fibers,  various  methods  have  been  devised  for  using  the 
sutures  so  as  to  obviate  their  tendency  to  tear  out.  Figs.  46,  47, 
and  48  illustrate  better  than  pages  of  description  some  of  these 
methods.  When  the  ends  of  tendons  are  approximated  laterally  the 
final  result  after  union  is  as  smooth  as  that  by  end-to-end  suture. 


MUSCLES,  TENDONS   AND    CELLULAR   TISSUES  177 

If  the  cut  ends  of  the  tendons  will  not  meet,  the  gap  is  bridged 
with  a  few  strands  of  suture  material,  preferably  chromicized  cat- 
gut or  kangaroo  tendon,  or  silk  and  catgut  both,  as  described  in 
tendon  lengthening. 

Tendons  may  be  attached  to  bone  by  raising  a  flap  of  peri- 
osteum at  the  desired  point  of  attachment  and  suturing  the  tendon 
to  that ;  or  by  raising  the  flap  of  periosteum,  guttering  the  bone 
underneath  it,  placing  the  tendon  or  graft  in  the  gutter  and  replac- 
ing the  periosteal  flap  with  sutures  through  both  the  tendon  and 
the  periosteum  to  hold  them  in  place.  As  a  rule,  attachment  to 
periosteum  is  more  satisfactory  than  attachment  to  paralyzed  ten- 
don, as  the  latter  is  apt  to  stretch. 

After  suturing  the  tendons,  the  wound  should  be  closed  with- 
out drainage.     It  is  not  usually  necessary  to   suture  the  opened 


Fig.    47.    Suter's    method    of    uniting    the    ends    of    tendons. — Archiv. 
fiir  Klin.  Chirurg.     1903-4. 

tendon  sheath.  Fascia  and  skin  are  sutured  separately.  The  skin 
should  not  be  too  tense.  Iodoform  gauze,  sterile  gauze  and  band- 
age follow,  and  a  plaster  of  Paris  bandage  over  all,  with  the  parts 
in  such  position  as  to  relax  the  tendon.  If  all  goes  well,  the  first 
dressing  is  not  disturbed  for  three  to  four  weeks.  If  union  is 
satisfactory,  massage,  and  later  passive  movements  will  aid  in  grad- 


178 


SURGICAL   DISEASES    OF   CHILDREN 


ually  establishing  function.  The  special  indications  for  these  opera- 
tions will  be  pointed  out  in  the  consideration  of  various  deformities. 

In  general,  it  may  be  said  of  tendon  transplantation  that  al- 
though scarring  is  unavoidable,  functional  results  are  good  if  a 
wise  arrangement  of  the  transplantation  is  chosen.  It  is  practi- 
cally useless  to  expect  to  get  a  result  that  is  worth  the  effort  and 
the  risk  of  the  procedure  by  transplanting  a  weak  muscle  to  take 
the  work  of  a  once  powerful  muscle. 

Results  are  most  satisfactory  when  a  sound  muscle  from  the 
same  group  as  that  of  the  paralyzed  one  is  available  for  transplant- 


FiG.  48.     Various   methods  of   suturing  tendons. 

Operative    Surgery." 


Binnie's    "  Manual    of 


ing.  The  result  should  at  least  hold  the  joint  midway  between 
flexion  and  extension,  and  therefore  correct  deformity  and  give 
movements  which  are  normal  in  their  direction  if  not  in  their 
power  or  extent.  In  spastic  cases  relief  from  spasm  may  be  ex- 
pected. It  is  the  opinion  of  men  of  experience  that  transplantation 
of  tendons  has  been  overdone  in  very  numerous  instances.  How- 
ever, this  is  apt  to  occur  in  the  history  of  any  operation,  and  one 
can  only  insist  upon  very  careful  preliminary  study  of  the  case 
before  any  operation  is  undertaken. 

FASCIA  AND  FAT-TISSUEi 

Fasciae  are  subject  to  all  the  injuries  and  inflammations  that 
affect   other  tissues.     Ordinarily  the   fasciae   receive   less   attention 
than  they  should  in  the  repair  of  wounds.     Care  should  be  taken 
1  See  also  Section  on  Anatomy,  Growth  and  Development. 


MUSCLES,  TENDONS  AND  CELLULAR  TISSUES  179 

to  approximate  severed  edges.  A  breach  in  a  fascia  covering  a 
voluntary  muscle  allows  protrusion  of  a  portion  of  the  muscle — a 
muscle  hernia.  In  suturing  incisions  or  wounds  in  fascia,  its  lack 
of  vascularity  should  be  remembered ;  and  also  its  frailness  in  the 
child.  Sutures  cut  out,  if  placed  near  the  margin  of  a  wound ;  or 
if  too  close  together,  on  account  of  the  poor  blood  supply  of  this 
tissue,  they  cause  pressure  necrosis.  Continuous  suture  should 
not  be  employed  in  fascia.  As  few  sutures  should  be  used  as  will 
serve  the  purpose,  and  they  should  be  placed  at  sufficient  distance 
from  the  margin  of  the  wound  and  not  too  tightly. 

Contraction  of  the  plantar  fascia  is  one  of  the  features  of 
many  cases  of  club  foot;  and  frequently  must  be  dealt  with  by 
operation.  The  fascia  is,  of  course,  not  the  only  offender  in  these 
cases,  but  its  unyielding  nature  often  makes  the  division  necessary. 
It  is  often  severed  beneath  the  deep  transverse  crease  across  the 
sole,  which  usually  shows  in  the  cases  in  which  the  fascia  needs 
division.  Division  at  several  points  may  be  necessary  before  the 
foot  is  sufficiently  released.  It  can  also  he  divided  a  short  distance 
anteriorly  from  the  os  calcis,  or  farther  forward  than  the  deep 
crease.  The  fascia  is  first  made  tense  by  the  hand  of  the  surgeon 
while  he  feels  for  the  worst  part  of  the  constriction.  The  foot  is 
then  relaxed  while  a  tenotome,  held  flat,  is  inserted  at  the  inner  edge 
of  the  fascia  and  passed  across  the  foot  between  the  skin  and  the 
fascia.  The  point  of  the  tenotome  should  not  emerge  through  the 
skin  at  the  outer  side,  but  only  go  as  far  as  the  outer  edge  of 
the  fascia.  The  edge  of  the  knife  is  then  turned  toward  the  fascia, 
which  is  now  made  tense,  and  is  divided.  The  tenotome  is  with- 
drawn, the  wound  dressed  v/ith  a  small  pad  of  iodoform  gauze  over 
the  opening,  covered  with  sterile  gauze,  bandaged  with  moderate 
pressure  at  the  site  of  the  section,  and  put  up,  usually  in  plaster 
of  Paris,  in  an  over-corrected  position. 

Fascia  and  Fat  in  Arthroplasty.  Fascia  with  fatty  tissue, 
have  been  put  to  novel  use  by  Murphy  and  others,  in  the  reconstruc- 
tion of  joints,  or  rather  in  the  construction  of  a  new  joint  where 
one  has  become  ankylosed.^  Langemak  has  pointed  out  that  while 
in  the  formation  of  the  joint  in  the  embryo  there  is  primarily  no 
cavity,  the  cavity  being  formed  by  a  splitting  or  liquefaction  of 
cartilaginous  or  connective  tissue  between  the  cartilages,  the  super- 
ficial bursae  are  made  by  a  similar  splitting  between  fat  capsules  on 
aponeurotic  mesoblastic  tissue.  The  bursa  formation  comes  about 
by  the  absorption  of  fat  from  the  fatty  tissue  and  the  coalescence  of 
the  small  fat  capsules  with  an  increase  or  hyperplasia  of  the  con- 
nective tissue  and  its  degeneration,  with  the  development  of  col- 
lagen. The  liquefaction  of  the  collagen  in  the  center  produces  the 
1  Murphy:  Trans.  Amer.  Surg.  Assn.,  1906,  xxii,  p.  315. 


i8o  SURGICAL  DISEASES  OF  CHILDREN 

fluid  in  the  bursa  or  hygroma.  The  cells  (in  reality  transformed 
connective  tissue  cells)  that  line  the  newly  developed  cavity  appear 
like  flattened  endothelial  cells.  Thus  fat  tissue  readily  changes  to 
connective  tissue  and  a  part  of  this,  under  pressure  takes  on  the 
appearance  and  duties  of  endothelium  while  a  degeneration-product 
of  the  fat  furnishes  a  solution  which  is  "fibrinoid"  and  not  a  serous 
secretion.  A  similar  process  is  seen  in  the  formation  of  a  hygroma 
in  the  false  joint  of  ununited  fracture  (see  Section  on  Ankylosis) 

(20). 

BURS-flE 

Wounds  of  bursse  are  treated  on  general  principles.  Hematoma 
of  a  bursa  may  be  due  to  trauma,  or  may  arise  with  or  without 
known  trauma  in  hemophilia.  It  is  usually  not  necessary  to  re- 
move a  clot  unless  it  becomes  septic.  Bursse  may  become  inflamed 
either  from  trauma  or  from  internal  infection  by  ordinary  pyogenic 
organisms,  or  the  pneumococcus  the  gonococcus,  the  bacillus  tuber- 
culosis, the  spirochetse  of  syphilis  and  probably  by  other  organisms. 
The  disease  may  be  acute  or  chronic,  simple  or  purulent,  according 
to  the  nature  of  the  cause.  The  symptoms  are  pain,  heat,  tender- 
ness and  swelling  localized  at  the  site  of  a  bursa  or  reflected  there- 
from. It  is  well  to  remember  that  bursse  may  develop  at  other 
sites  than  those  anatomically  normal,  where  long-continued  pressure 
or  friction  are  brought  to  bear,  and  that  such  adventitious  bursse 
are  especially  liable  to  inflammation. 

The  treatment  of  the  acute  forms  is  similar  to  that  described  for 
teno-synovitis.  In  the  tubercular  form  the  bursa  may  be  dissected 
out  and  the  wound  closed.  Or  the  diseased  bursa  be  entirely 
curetted  out,  swabbed  with  carbolic  acid  followed  by  alcohol, 
packed  with  formidine  gauze,  to  heal  by  granulation.  Hemophiliac 
hemorrhages  into  bursse  may  be  treated  locally  as  simple  inflamma- 
tions. 

CELLULAR  TISSUES 

The  cellular  tissues  are  the  seat  of  ecchymoses  and  of  hema- 
tomata  as  a  result  of  contusions  and  in  hemophilia.  Ordinary  ex- 
travasations from  contusions  and  even  some  hematomata  may  clear 
up  with  the  use  of  either  cold  or  heat.  But  if  a  subcutaneous  hema- 
toma of  large  size  does  not  show  evidence  of  reabsorption  in  a 
week  or  two  it  should  be  cut  down  upon  and  evacuated,  under 
antiseptic  precautions,  and  the  wound  closed  with  the  expectation 
of  securing  immediate  union.  If  the  patient  is  hemophiliac,  opera- 
tive measures  should  not  be  employed.  Cephal-hematoma  of  the 
new-born  requires  operation  in  fracture,  compression  or  suppuration. 

The  cellular  tissues  are  very  often  the  seat  of  infectious  inflam- 
mations.    (See  Section  on  Cellulitis.) 


CHAPTER  VII 

RICKETY   DEFORMITIES 

Genu  Valgum  (Knock-Knee) — Genu  Extrorsum  (Genu 
Varum) — Bow-Legs,  Corkscrew  and  Saber-Legs — Rickety 
Deformities  of  the  Forearms — Rickety  Deformities  of 
the  Thorax, 

GENU    VALGUM    (KNOCK-KNEE) 

This  is  a  common  deformity  among  children,  and  when  occur- 
ring in  them,  as  it  is  apt  to  do,  between  the  time  of  learning  to 
walk  and  the  fourth  year,  it  is  generally  attributed  to  rickets.  At 
a  later  period  also,  perhaps  from  the  twelfth  to  the  seventeenth  or 
eighteenth  year,  knock-knee  may  develop.  In  this  class  of  cases 
it  is  attributed  to  muscular  and  ligamentous  weakness  resulting 
from  the  overtaxed  vitality  of  the  adolescent  period.  We  should 
not  forget  that  rickets  is  a  disease  affecting  the  nutrition,  not  only 
of  bone,  but  of  cartilages,  muscles,  tendons  and  ligaments  as  well, 
and  that  it  also  lowers  innervation  and  consequently  muscular  to- 
nicity ;  thus  it  is  not  difficult  to  understand  the  method  of  the  produc- 
tion of  deformities.  Any  yielding  of  ligament  to  tensile  stress,  or 
slight  overgrowth  or  undergrowth  of  cartilage  that  misplaces  a 
limb  from  its  center  of  stress,  gives  opportunity  for  further  de- 
formity when  the  weight  of  the  body  acts  upon  the  deviated  sup- 
port. Suppose  that  a  weak  plantar  arch,  which  is  not  reinforced 
by  strong  flexor  tendons,  allows  the  inner  side  of  the  foot  to  settle 
flat  upon  the  floor,  the  tibia  has  lost  a  part  of  its  support  upon  the 
inner  side.  This  has  a  tendency  to  tilt  the  knee  inward,  lessening 
compressive  stress  upon  the  internal  and  increasing  it  upon  the 
external  condyles.  This  uneven  pressure  would  cause  the  internal 
condyle  to  grow  more  rapidly  and  increase  the  lateral  angulation  of 
the  joint.  The  origin  of  knock-knee  has  also  been  explained  as  due 
to  obliquity  of  the  attachment  of  the  epiphysis  to  the  diaphysis. 
Some  consider  it  primarily  an  in-bend  of  the  upper  third  of  the 
tibia,  or  a  bend  in  the  lower  part  of  the  femoral  shaft,  and  not 
caused  by  elongation  or  shortening  of  condyles. 

It  may  be  that  the  beginning  of  the  trouble  is  not  the  same 
in  all  cases,  and  this  is  borne  out  by  the  fact  that  knock-knee  may 
result  from  chronic  joint  or  bone  disease.  In  the  usual  case  we 
find  the  inner  condyle  prolonged,  while  the  lower  end  of  the  femur 

l8i 


i82  SURGICAL   DISEASES    OF   CHILDREN 

curves  down  to  it  (see  Fig.  49),  the  internal  lateral  ligaments  being 
elongated.  ^Jost  cases  are  accompanied  by  flatfoot.  Sometimes 
one  and  again  both  knees  are  affected,  or  one  knee  may  be  valgous 
while  the  other  is  bowed.     It  is  usual,  too,  to  find  other  evidences 


Fig.  49.     Radiograph  of  kxock-kxee.     Same  case  as  Figs.  51  and  52. 

of  rickets  in  some  part  of  the  child's  anatomy,  and  other  relaxed 
joints,  and  to  get  a  history  of  that  plan  of  feeding  and  manner 
of  living  which  induces  rachitis.     (See  Section  on  Rachitis.) 

Complete  flexion  effaces  the  valgous  deformity,  the  leg  lying 
directly  behind  the  thigh,  while  the  long  projection  of  the  internal 
condyle  is  very  evident.  On  full  extension  the  deformity  is  at  its 
worst;  the  patella  is  almost  over  the  external  condyle  and  the  ex- 
cessive lateral  motion  of  the  joint  exposes  its  weakness.  The  child 
will  complain  of  pain  and  tenderness  over  the  inner  side  of  the 
knee,  and  of  being  tired,  especially  after  he  has  been  long  on  his 
feet. 

Treatment, — Before  beginning  any  treatment  it  is  well  to  make 


RICKETY   DEFORMITIES  183 

a  record  of  the  degree  of  deformity  in  order  that  improvement  may 
be  noted.  By  placing  a  large  sheet  of  paper  upon  the  table,  laying 
the  child  with  his  limbs  extended  upon  it,  with  a  pencil  held  verti- 
cally, a  tracing  of  their  outline  upon  the  paper  can  readily  be 
made.  In  lieu  of  this  the  knees  may  be  placed  firmly  together,  and 
with  the  limbs  fully  extended  the  distance  between  the  internal 
maleoli  can  be  measured. 

There  are  several  plans  of  treatment  from  which  to  choose. 
There  is  the  expectant  plan  for  the  indolent  and  optimistic.  But 
the  poor  child  has  to  take  the  unfortunate  consequences.  Some 
cases  do  improve  spontaneously.  However,  the  condition  is  more 
apt  to  get  worse  or  remain  permanent.  So  the  expectant  plan 
is  not  recommended.  In  the  choice  of  treatment  one  is  guided 
partly  by  the  age  of  the  patient.  If  he  is  quite  young,  say  under 
four  years,  the  deformity  can  probably  be  corrected  without  opera- 
tion. That  depends  upon  the  degree  of  the  deformity,  but  still 
more  upon  the  pliability  of  the  tissues  under  corrective  measures 
and  the  response  of  the  general  health  to  improved  nutrition  and 
hygiene.  An  extreme  degree  of  deformity  may  be  the  result  of 
such  soft  and  yielding  structures  that  if  the  bones,  particularly 
the  inner  condyle,  have  not  firmly  ossified  in  their  faulty  shape,  cor- 
rection may  be  more  easily  made  than  in  a  less  marked  deformity 
with  rigid  structures  to  deal  with.  With  structures  which  are  soft 
and  yield  readily,  the  best  way  to  rapidly  restore  the  symmetry  of 
the  limb  is  to  take  the  child  entirely  off  his  feet  and  apply  a  padded, 
straight,  flat  splint  to  its  outer  side  from  the  thigh  to  below  the 
ankle,  encircling  the  thigh,  the  leg,  and  especially  the  knee,  with 
wide  bands  that  by  being  buckled  firmly  draw  the  limb  to  the  splint. 
If  both  limbs  are  deformed  the  splint  may  be  placed  between  them 
or  simply  a  cushion  between  the  knees,  and  bands  of  leather  or 
webbing  to  draw  the  legs  toward  the  middle  line.  The  bands 
should  not  be  of  elastic  webbing.  For  a  time  the  child  may  be 
kept  upon  his  back  with  the  limbs  thus  splinted  and  a  sandbag 
or  a  back-splint  to  the  limbs  to  keep  them  extended  so  that  the  cor- 
recting bands  can  exert  their  pressure  in  the  right  direction.  The 
limbs  and  the  back  should  be  carefully  bathed,  oiled  and  massaged 
morning  and  evening,  and  handled  and  readjusted  several  times  a 
day,  while  the  child's  diet  and  digestion  and  his  general  health 
should  be  carefully  attended  to.  If  one  can  secure  faithful  and 
intelligent  care  the  deformity  will  promptly  be  removed  and  the  pa- 
tient can  be  allowed  up  and  about  again,  with  strength  and  devel- 
opment so  much  improved  that  with  proper  attention,  even  with- 
out the  use  of  a  light  brace  or  of  the  splint  at  night,  it  will  not 
return.  The  great  difficulty  in  this  plan  is  in  securing  faithful  co- 
operation of  the  mother  or  nurse  in  following  it  out.     The  plea  is 


l84 


SURGICAL   DISEASES    OF   CHILDREN 


made  that  the  child  wants  to  be  up  and  that  it  is  impossible  to  keep 
him  in  bed,  though  finally  the  true  reason  is  confessed  that  "  It's 
too  much  trouble,"  and  a  demand  is  made  for  braces.  Knock-knees 
can  be  gradually  straightened  by  the  use  of  braces,  though  this 
method  is  inferior,  especially  in  young  children.  The  brace  or  splint 
must  start  from  a  pelvic  band  of  steel,  extend  down  the  outer  side 
of  the  limb,  having  antero-posterior  joints  at  hip  and  ankle  and  a 
lateral  joint  at  the  knee.  The  lower  end  is  fastened  to  the  shoe. 
In  quite  a  few  of  these  cases  an  arched  metal  insole,  or  sometimes 
careful  strapping,  is  necessary  to  correct  the  flatfoot.    Although  in 

some  cases,  when  once  the  knock-knee  is 
corrected,  the  flatfoot,  which  often  was 
a  result  of  faulty  weight-bearing,  soon 
disappears.  The  knee  hinge  has  a  rack 
and  pinion  by  which  its  angle  can  be 
straightened  a  little  every  few  days.  The 
thigh-,  knee-,  and  leg-bands  should  be 
well  padded,  and  the  skin  beneath  them 
should  be  carefully  kept  sound.  (See  Fig. 
50.)  Another  style  of  brace  is  made 
without  a  knee  joint.  It  will  probably  be 
necessary  to  wear  the  brace  a  year  or 
two. 

Instead  of  using  steel  braces,  the  knock- 
knee  may  be  corrected  by  putting  up  the 
limb  in  a  plaster  bandage  while  it  is  held  in 
the  best  position  possible  during  the  ap- 
plication of  the  bandage.  The  bandage 
should  extend  from  the  ankle  to  the  peri- 
neum, and  should  be  removed  and  re- 
placed every  ten  days  or  two  weeks.  One  dislikes  to  see  the  child 
meanwhile  walking  upon  a  flat-foot.  The  flat-foot  can  be  treated  at 
the  same  time  as  the  knock-knee  by  manipulating  it  and,  after  cor- 
rection, putting  it  up  in  plaster  and  then  extending  the  plaster  on  up 
the  limb  to  the  perineum,  while  holding  the  limb  as  straight  as  pos- 
sible. The  rickety  softness  of  the  bones  may  change  to  the  hard- 
ness of  eburnation,  which  is  as  hard  as  adult  bone,  in  from  two  to 
four  months. 

Operative  Treatment. — In  former  years,  in  fact,  no  longer  ago 
than  1885,  when  Mr.  Edmund  Owen  wrote  his  admirable  treatise, 
the  redressement  force  of  knock-knee  was  considered  admissible 
under  certain  circumstances.  With  the  child  under  chloroform,  the 
surgeon  grasps  "  the  thigh  in  one  hand  and  the  middle  of  the  leg 
in  the  other,  and  with  his  knee  near  or  against  the  prominent  angle 
of  the  extended  knee  of  the  child  he  straightents  it  gently  yet  firmly, 


Fig.   50.     Plain 
knock-knee  brace. 


RICKETY   DEFORMITIES  185 

as  he  would  a  stick."  Then  the  limb  was  put  in  straight  splints.  It 
was  realized  that  no  one  could  know  exactly  what  happened  during 
this  maneuver ;  whether  the  inner  condyle  was  pushed  up  or  the 
external  lateral  ligaments  yielded,  or  the  epiphysis  became  detached. 
But  this  is  the  method  we  were  taught  and  practiced  at  that  time, 
until  the  pioneer  work  of  Ogston,  of  Reeves  and  Macewen,  under 
the  protection  of  antiseptic  surgery,  demonstrated  the  safety  and 
greater  certainty  of  osteotomy,  and  forcible  straightening  was  prac- 
tically abandoned,  although  excellent  results  had  been  obtained  by 
its  use. 

Since  that  time,  too,  there  has  been  a  gradual  change  of 
opinion  and  practice  concerning  the  proper  age  for  operation.  As 
Owen  records,  Ogston  was  of  opinion  that  most  cases  of  knock- 
knee  under  puberty  are  curable  without  cutting  operation ;  that 
Bacher  would  not  operate  earlier  than  the  sixth  year ;  that  Macewen 
would  not  operate  on  any  patient  under  nine  years  of  age  at  the 
very  least,  and  would  prefer  them  to  be  fifteen  or  more ;  and  Bar- 
well  would  not  operate  before  the  seventh  3'ear.  Nowadays  four 
years  is  about  the  dividing  line,  so  far  as  it  can  be  indicated  by  age, 
between  those  who  should  be  treated  for  knock-knee  or  bow-legs 
with  splints  or  braces  and  those  who  should  be  subjected  to  osteot- 
omy, or  osteoclasis.  Obviously  the  guiding  principle  should  be  to 
have  the  bone  and  other  tissues  so  far  ossified  and  strengthened  that 
the  results  of  an  operation  will  be  permanent,  and  that  these  results 
are  such  as  could  not  be  obtained  without  operation  by  any  reason- 
able amount  of  treatment  with  braces.  When  it  is  found  that  a 
child  at  four  or  at  five  or  six  years  relapses  after  correction  by 
either  braces  or  osteotomy,  then  it  is  known  that  the  child  did  not 
need  an  operation,  for  the  tissues  yield  readily  without  it,  and  the 
braces  are  a  necessity  after  all  to  maintain  the  correction.  The 
question  is  not  answered  by  the  age  of  the  patient,  but  by  the  condi- 
tion of  the  tissues,  and  this  must  be  left  to  the  judgment  of  the  sur- 
geon. One  should  not  allow  mere  impatience  for  results  to  induce 
him  to  take  even  a  slight  risk  of  the  patient's  life  or  limb,  or  even 
of  his  own  reputation.  On  the  other  hand,  it  is  useless  to  burden 
a  child  with  braces  and  his  parents  with  endless  work  and  annoy- 
ance in  the  care  of  them,  after  his  bones  have  become  hardened  or 
even  eburnated  and  his  ligaments  permanently  elongated  or  con- 
tracted in  a  position  of  deformity.  Nor  should  he  be  allowed 
through  indecision  or  inattention  to  fall  between  two  stools,  and  go 
without  either  braces  or  operation.  There  are  cases  five  or  six 
years  old  which  will  recover  perfectly  with  a  year  or  two  of  braces, 
and  there  are  cases  only  four  years  old  which  ought  to  be  operated. 
As  a  rule,  if  the  strength  of  the  surgeon's  hands  gently  but  steadily 
applied  is  not  sufficient  to  bend  the  bones  noticeably,  they  will  not 


i86 


SURGICAL   DISEASES    OF   CHILDREN 


yield  to  braces.  In  case  of  doubt,  or  of  indecision  on  the  part  of 
the  parents,  a  padded  splint  may  be  applied  for  a  week  or  two,  and 
the  effect  noted.  No  child  in  a  depraved  state  of  health  or  recently 
exposed  to  any  contagion  ought  to  be  subjected  to  a  bone  operation, 
nor,  for  that  matter,  to  any  other  elective  operation. 

Osteoclasis  is  not  well  adapted  for  work  very  near  a  joint. 
Osteotomy  is  the  operation  of  choice  with  many  surgeons,  al- 
though some  prefer  osteoclasis.     In  osteotomy  Macewen's  operation 


51 
years. 
Home 


Knock-knee.      Aged    4 
Case     at     Holy     Cross 


Fig.    52.      Same    case 
after    osteotomy. 


is  the  one  most  approved.  Ogston  partially  divided  the  internal  con- 
dyle with  a  saw,  avoiding  entering  the  joint,  and  then  pushed  up  the 
projecting  condyle  by  lateral  traction  on  the  leg.  Reeves  used  a 
chisel  instead  of  a  saw.  Macewen  went  above  the  epiphyseal  line 
and  partially  divided  the  diaphysis  with  a  chisel,  so  that  it  could  be 
fractured  across  by  straightening  the  limb.  Macewen  entered  the 
osteotome  from  the  inner  side  of  the  thigh.  Many  operators,  my- 
self included,  prefer  the  outer  side.  There  is  really  little  difference 
(18).  After  careful  antiseptic  cleansing,  the  limb  is  Esmarched. 
flexed  to  a  right  angle,  and  the  knee  laid  firmly  on  a  sandbag. 
Some  operators  omit  the  Esmarch,  and  this  is  just  as  well,  for  there 


RICKETY    DEFORMITIES 


187 


is  very  little  blood  lost;  and  if  by  any  possible  accident  a  larger 
vessel  is  cut  it  will  be  known  at  once ;  and  also,  there  is  less  oozing 
afterward.  A  longitudinal  incision,  about  an  inch  long,  just  high 
enough  to  avoid  injuring  the  epiphyseal  line,  is  carried  directly 
down  upon  the  center  of  the  shaft  of  the  femur.  Before  removing 
the  knife  the  osteotome  is  passed  beside  it  till  it  rests  upon  the  bone, 
when  the  knife  is  removed.  The 
osteotome  is  then  turned  so  that 
its  cutting  edge  is  across  the 
bone.  The  osteotome  must  be 
firmly  held  while  it  is  struck 
steadily  with  a  mallet.  There  is 
no  danger  of  doing  injury  unless 
the  osteotome  is  held  obliquely 
pointed  backward  and  allowed 
to  slip  off  the  bone  when  struck. 
With  a  few  strokes  it  can  be  felt 
to  enter  the  medullary  canal,  and 
then  enter  solid  bone  on  the  far- 
ther side.  The  osteotome  should 
not  be  driven  clear  through  the 
bone.  No  effort  should  be 
made  to  try  the  strength  of  the 
bone  by  using  the  osteotome  as 
a  lever,  but  ic  can  be  loosened 
by  lateral  movements  The  os- 
teotome is  usually  graduated 
with  marks  upon  its  side  for 
measuring  the  depth  to  which  it 
has  entered;  but  the  best  guide 
is  the  sense  of  the  hand  that 
holds  the  osteotome.  When  it 
appears  that  the  bone  is  suffi- 
ciently cut,  the  operator  grasps 
the  leg  in  one  hand  and  with 
counter  pressure  near  the 
wound  breaks  the  bone.  Iodo- 
form and  sterile  gauze,  cotton  and  bandage  are  quickly  applied,  the 
limb  held  straight  and  encased  in  plaster  and  the  Esmarch  constrictor 
removed.  Unless  something  goes  wrong,  such  as  blood  oozing 
through  the  dressings  or  the  foot  swelling  or  becoming  bluish,  or 
continued  pain  or  high  temperature,  the  dressing  is  not  changed  for 
a  month.  There  is  no  necessity  for  passive  motion  after  ten  days, 
as  with  Ogston's  operation.  Usually  the  result  is  perfect  union. 
But  a  splint  or  a  plaster  bandage  is  in  orcjer  for  a  while  longer, 


Fig.  53.  Genu  valgum.  Also  tu- 
berculous. Has  lost  an  index 
finger  and  has  many  scars  from 
tuberculous  lesions.  Treated  in 
New  York  for  tuberculosis  of 
right  knee.  Osteotomy  of 
femurs  at  Cleveland  City  Hos- 
pital by  the  author.  Result 
shown  in  Figs.  54  and  55.  Girl 
aged  12  years. 


i88 


SURGICAL   DISEASES    OF    CHILDREN 


especially  if  the  bone  cut  soft,  and  on  leaving  it  off  the  limb  should 
be  watched  for  a  time  to  see  that  it  does  not  bend.  (See  Figs.  51 
to  55-) 

Osteoclasis  will  be  described  lin  the  Section  on  Bow-legs,  and 
Corkscrew  and  Saber-legs. 

GENU    EXTRORSUM     (GENU    VARUM) 

Genu  Extrorsum   (Genu  Varum,  Bandy-leg,  Out-knee)  is  due 
to  bowing  outward  of  the  femur,  and  sometimes  also  of  the  leg- 


FiG.     54.       Same    case    as     Fig.    53.       Fig.   55.      Same   case   showing   result 
Wearing     casts     4     weeks      after  of   osteotomy   of   femurs   for   genu 

operation.  valgum. 

bones,  the  knee  joint  not  being  at  fault.  The  cause  is  rickets.  The 
bones  being  soft,  yield  to  muscular  action  and  weight,  while  the 
ligaments  being  stronger  in  proportion,  hold  the  joint  in  proper 
shape.     Sometimes  the  femur  only  is  bent. 

Treatment. — The  remarks  upon  knock-knee  are  entirely  appli- 
cable to  this  condition  as  regards  its  curability  by  rest  and  splints 
and  also  as  to  the  time  for  resorting  to  operation.  It  is  true  that 
spontaneous  cure  may  possibly  result  under  improved  hygiene  and 
increased  general  vigor ;  but  it  is  equally  true  that  such  fortunate 
outcome  is  not  to  be  depended  upon,  and  also  that  when  the  bones 
have  hardened  in  deformity  there  is  no  possibility  of  their  improv- 


RICKETY   DEFORMITIES  189 

ing  spontaneously.  Under  these  conditions  osteoclasis  or  osteot- 
omy of  the  femur  is  the  only  resort,  and  if  that  bone  only  is  at 
fault,  will  give  entire  satisfaction.  If  the  leg-bones  also  are  bent,  it 
may  be  necessary  to  operate  also  upon  them. 

BOW-LEG,  CORKSCREW  AND  SABER-LEG 

Bow-legs  is  the  most  common  variety  of  rickety  deformity 
that  needs  the  services  of  the  surgeon.  It  may  accompany  bowing 
of  the  thigh,  or  it  may  be  present  without  other  rickety  deformity. 
It  may  affect  one  leg  only  or  both ;  or  one  leg  may  be  bowed  and 
the  other  valgous.  If  the  thighs  be  brought  together  in  the  middle 
line  the  crossing  of  the  legs  that  is  rendered  necessary  gives  one 
an  appreciation  of  the  degree  of  the  bowing.  It  can  be  measured  by 
placing  the  internal  maleoli  together  and  noting  the  number  of 
inches  between  the  knees,  and  it  can  be  graphically  recorded  by 
placing  the  legs  flat  upon  a  large  sheet  of  paper  and  tracing  their 
outlines.  The  greatest  bend  is  often  about  the  junction  of  the  upper 
and  middle  thirds  of  the  tibia,  but  sometimes  it  is  near  the  middle 
and  lower  thirds.  Sometimes  the  curve  <is  convex  forward,  in 
which  case  it  is  apt  to  be  about  the  middle  and  lower  thirds  or  in 
the  lower  third.  This  bowing  forward  is  often  called  saber-leg,  but 
is  not  to  be  confused  with  the  anterior  bowing  or  saber-leg  of  late 
hereditary  syphilis.  Occasionally  the  tibia  bends  in  several  different 
directions,  for  instance,  outward  above  and  forward  lower  down, 
with  a  spiral  twist  in  its  lower  third  which  has  given  rise  to  the 
name  corkscrew-leg.  However,  these  deformities  are  all  due  to  the 
same  cause,  rachitis,  modified  by  habitual  position,  slight  differences 
of  muscular  action  and  the  like.  Other  evidences  of  rickets  can 
usually  be  found.  Older  children,  in  whom  the  active  stage  is 
past,  usually  have  some  memento  remaining  in  the  form  of  enlarged 
radial  epiphyses,  projecting  lower  ribs,  pigeon-breast,  or  a  large, 
square-cornered  cranium.  Flat-foot  may  accompany  bow-leg, 
though  it  is  not  as  constantly  present  as  with  knock-knee.  Perhaps 
the  tilting  over  upon  the  outer  border  of  the  foot  saves  the  arch 
somewhat. 

The  diagnosis  presents  no  difficulty. 

The  prognosis  is  unpromising  if  the  deformity  is  untreated. 
With  proper  treatment  the  result  is  likely  to  be  extremely  satis- 
factory. 

Treatment. — Young  children  whose  rachitic  bones  are  still  pli- 
ant may  be  treated  by  rest  in  splints,  with  anti-rachitic  diet,  baths, 
massage,  and  manual  pressure.  Or  the  legs,  held  as  straight  as  pos- 
sible, may  be  put  up  in  plaster,  and  these  casts,  with  manual  cor- 
rection, renewed  at  intervals  of  ten  to  fifteen  days  for  a  few  months. 
By  the  time  the  attack  of  rickets  has  subsided  the  bones  will  be 


190 


SURGICAL   DISEASES    OF   CHILDREN 


Fig.  56. 

Long    single    bar 

bowleg  brace. 


Straight,  and  will  harden  in  the  corrected  position.  An  alternative, 
though  not  a  superior  method,  is  by  braces.  (See  Figs.  56  and  57.) 
(See  remarks  on  Treatment  of  Knock-knee.)  By 
these  methods  cure  may  be  effected  in  a  few 
months  or  a  year  in  suitable  cases.  If  a  splint  is 
to  be  used,  it  is  simply  flat  and  padded,  with  the 
leg  strapped  upon  it.  If  both  legs  are  bowed,  either 
two  splints  may  be  used,  or  one  between  the  legs 
from  above  the  knees  to  below  the  feet,  with  en- 
circling strap  at  the  ankles,  one  at  the  knees,  and 
one  around  the  convexity.  This  makes  a  simple 
but  efficient  apparatus.  If  braces  are  to  be  used, 
they  can  be  made  to  reach  only  from  the  feet  to 
the  middle  of  the  thigh,  but  they  keep  their  place 
better  if  extended  to  a  pelvic  band.  They  need 
not  be  heavy,  as  they  are  not  intended  to  support 
the  entire  weight  like  a  Thomas  knee  splint  or 
a  Taylor  hip  brace.  The  upright  for  the  inner 
side  of  the  leg  should  be  strong  enough  to  with- 
stand some  pressure,  for  from  this  a  wide,  padded 
band  surrounds  the  leg  at  its  greatest  convexity 
and  is  tightened  at  intervals  of  a  few  days  or 
weeks  as  the  leg  straightens.  Two  pads  upon 
the  inner  upright  of  the  brace,  one  at  the  in- 
ternal condyle  and  one  at  the  inner  maleolus, 
make  counter  pressure.  Braces  are  useless  in 
the  treatment  of  saber-leg,  or  anterior  bow- 
ing of  the  tibia.  When  the  bones  have  hard- 
ened, which  is  usually  the  case  in  children  past 
four  years  of  age,  and  sometimes  younger, 
the  best  treatment  is  osteotomy  or  osteoclasis. 
Osteotomy. — In  osteotomy  the  section  is 
made  at  the  point  of  greatest  convexity.  The 
technique  is  that  described  in  osteotomy  for 
knock-knee.  But  with  osteotomy  upon  the 
lower  part  of  the  tibia  it  is  generally  necessary 
first  to  tenotomize  the  tendo  Achillis,  as  it 
persistently  prevents  straightening  of  the  bone 
or  pulls  upon  the  lower  fragment  when  it  is 
placed  in  line.  (See  Tenotomy  of  Tendo 
Achillis.)  All  these  operations  are  done  un- 
der strictest  antiseptic  precautions.  Osteot- 
omy can  be  employed  for  ordinary  bow-leg  as 
well  as  for  saber  or  corkscrew  leg,  and  is 
often  chosen  in  preference  to  osteoclasis  by 
general  surgeons  who  are  not  familiar  with 


Fig.  57.     Boston 

children's  hospital 

bowleg    brace. 


RICKETY   DEFORMITIES 


191 


the  use  of  the  osteoclast  or  have  not  one  at  hand.  If  a  wedge  of  bone 
is  removed  from  the  convexity,  for  instance,  in  saber-leg,  the 
bone  is  shortened.  This  is  a  distinct  disadvantage,  as  the  de- 
formity has  already  shortened  the  bone  and  lowered  the  patient's 
stature.  The  removal  of  a  wedge  should  be  avoided.  Osteotomy, 
whether  for  tibia  or  femur,  is  not  an  operation  to  be  lightly  or 


Fig.      58.   _    Bow-legs.        Osteotomy,       Fig.    59.      Same    case    after    oste- 
both    tibiae.      Wore   casts  4  weeks.  otomy.     Never  wore  any  braces 

Aged  4  years  and  3  mos.  after  casts  were  removed. 

thoughtlessly  undertaken.  Ordinarily  it  is  easy  of  execution  and 
a  safe  and  very  satisfactory  operation,  and  yet  excellent  surgeons 
have  occasionally  gotten  into  difficulty  over  it ;  and  cases  are  on 
record  of  septicemia,  pyemia,  fat  embolism,  non-union,  necrosis, 
recurrent  hemorrhage  and  other  serious  and  fatal  effects  resulting 
from  osteotomy  in  the  hands  of  competent  and  careful  surgeons. 
In  osteotomy  an  Esmarch  may  be  used  or  not,  as  desired.  The  in- 
cision is  longitudinal,  at  the  point  of  greatest  convexity,  and  upon 
that  side  of  the  bone  nearest  the  surface,  and  goes  down  to  the 


192 


SURGICAL   DISEASES    OF   CHILDREN 


periosteum.  The  osteotome  is  passed  into  the  wound  flatwise  be- 
side the  blade  of  the  knife.  The  knife  is  removed.  The  osteotome 
is  given  a  quarter  turn,  so  that  its  cutting  edge  is  at  right  angles 
with  the  long  axis  of  the  bone,  and  is  held  firmly  in  the  whole  hand 
and  driven  into  the  bone  with  measured   strokes   by  the  mallet. 

When  the  bone  is  cut  about 
two-thirds  of  the  way  through, 
the  osteotome  is  removed  and 
the  bone  fractured  by  manual 
strength.  It  is  not  necessary  to 
cut  the  fibula,  as  it  can  generally 
be  broken  with  the  hands. 
Neither  is  it  often  necessary  to 
remove  a  wedge  of  bone  from 
the  convex  side  of  the  curve. 
The  skin  wound  is  sutured  with 
catgut  and  a  surgical  dressing 
applied.  The  limb  is  placed  in 
a  corrected  or  slightly  over-cor- 
rected position.  If  there  are 
other  bends  in  the  limb  in  the 
same  direction  as  the  one  cor- 
rected, sufficient  over-correction 
should  be  used  to  neutralize 
them.  This  position  blends  in 
with  the  other  curves,  giving  a 
generally  symmetrical  contour. 
The  limb  is  then  put  up  in  plas- 
ter, including  the  foot  and  the 
knee,  and  if  all  goes  well  the 
dressing  is  not  changed  for  a 
month.  In  case  of  discharges 
through  the  dressings,  continued  fever  above  loi  or  102  degrees 
F.,  or  dusky-colored  toes  or  pain  after  the  first  day  or  two,  the 
wound  must  be  inspected.  After  the  first  cast  is  removed  the  limb 
should  be  guarded  for  a  time  by  a  cast  or  splint,  or  care  taken 
lest  recurrence  follow  while  the  union  is  still  new.  (See  Figs.  58, 
59,  and  60.) 

Osteoclasis  consists  in  producing  a  simple  fracture  by  means 
of  an  instrument.  This  instrument,  called  an  osteoclast,  is  in  sev- 
eral varieties.  In  some  the  power  is  applied  by  a  screw  and  in  others 
by  a  lever  or  levers.  Each  has  its  advocates,  and  each  is  best  in 
the  hands  of  the  man  accustomed  to  its  use.  The  screw  applies 
the  power  accurately  where  it  is  placed,  but  slowly — some  say  too 
slowly.  Not  more  than  eight  seconds  under  pressure  should  be 
required  to  fracture  a  bone  (Blanchard).    The  lever-power  osteo- 


FiG.  60.  Same  case  as  Figs.  58 
and  59.  Six  years  after  oper- 
ation  showing  no   relapse. 


RICKETY   DEFORMITIES 


193 


clasts  act  quickly,  with  very  little  bruising-  of  tissues,  but  require 
some  practice  for  accurate  and  rapid  use.     The  Grattan  osteoclast 
is  an  excellent  instrument.     It  is  one  of  the  screw  variety,  (ig) 
Osteoclasis  may  be  used  upon  any  long  bone  that  it  is  neces- 


FiG.     61. 


Knock-knees. — Dr. 
Blanchard. 


Wallace  Fig.  62.  Same  case  after  cor- 
rection by  rapid  osteoclasis 
above  the  condyles. 

sary  to  fracture  not  too  near  a  joint,  if  the  bone  is  not  subcutane- 
ous where  the  instrument  must  apply  its  force.  For  instance,  in 
saber-leg  the  pressure  must  be  applied  laterally  and  not  anteriorly. 


194  SURGICAL  DISEASES    OF   CHILDREN 

Osteoclasis  has  the  advantage  of  not  making  an  external  wound, 


Fig.  63 a.  Florence  W.,  aged  4 
years.  Badly  deforming  rachitic 
knock-knee  of  right  side,  and 
bow-leg  of  left  side,  producing 
difficult  locomotion.  For  cor- 
rection two  supercondyloid  and 
four  tibial  fractures,  to  which 
may  be  added  four  correspond- 
ing fractures  of  the  fibulas,  ten 
in  all  were  necessaiy. 


Fig.  63B.  Same  case  after  correc- 
tion by  rapid  osteoclasis,  open- 
ing up  of  triangular  spaces,  ro- 
tation and  readaption  of  frac- 
tured ends.  A  skiagraph  taken 
six  months  afterward  showed 
only  slight  shadows  to  indicate 
the  extensive  fracturing  and  re- 
dressment  of  the  bones. — Dr. 
Wallace   Blanchard. 


nor  necessarily  opening  the  periosteum.     There  may  not  even  be  a 
skin  abrasion,  yet  it  is  well  to  cleanse  the  limb  antiseptically  before 


RICKETY   DEFORMITIES 


195 


bib  cfl"i« 

_  2  be  til 
co^  o 

•»H      CO 

■  c  ° 


h 


oeq 


196  SURGICAL  DISEASES  OF  CHILDREN 

operating.  The  principle  of  osteoclasis  is  readily  understood.  The 
screw  or  the  fulcrum  actuated  by  the  lever  or  pair  of  levers  is 
placed  over  the  greatest  convexity  of  the  bow,  unless  the  bone  is 
subcutaneous  at  that  point.  The  rings  of  the  instrument  encircle 
the  ends  of  the  bow  and  the  force  is  applied  as  rapidly  as  may  be 
till  the  bone  snaps  or  straightens.  Usually  transverse  fracture 
occurs.  If  it  straightens  without  snapping  (osteokampsis),  it  is 
best  to  carry  it  a  little  beyond  the  straight  line.  Sometimes  it  is 
a  green-stick  fracture,  but  often  the  bone  is  eburnated  and  almost 
ivory-like,  and  breaks  sharply.  In  case  of  osteoclasis  upon  the 
lower  part  of  the  leg,  the  tendo  Achillis  is  tenotomized  just  before 
the  osteoclast  is  applied.  Otherwise  its  traction  would  misplace  the 
fragments.  In  saber  leg  or  anterior  bowing,  after  fracture  by  the 
osteoclast  the  lower  end  of  the  tibia  is  brought  forward  to  straighten 
the  shaft.  The  fracture  being  transverse,  this  position  opens  a  tri- 
angular space  posteriorly  between  the  fragments.  But  this  is  filled 
in  during  the  healing  process,  and  nearly  an  inch  is  gained  in  the 
length  of  the  bone.  The  limb  is  held  in  such  position  as  to  neu- 
tralize abnormal  curves  and  give  a  symmetrical  appearance.  Anti- 
septic gauze  and  plaster  bandage  complete  the  work.  The  subse- 
quent course  after  osteoclasis  is  that  of  a  simple  fracture  without 
displacement.  Children  mind  this  operation  but  little  and  generally 
give  admirable  results,  as  seen  in  Figs.  61  to  67. 

COXA  VARA 

Depressed  neck  of  the  femur  is  a  static  deformity  sometimes 
caused  by  rachitis,  less  frequent  in  childhood  than  in  adolescence, 
the  femoral  neck  being  short  in  early  life.  The  depression  may 
change  the  angle  from  an  obtuse  to  a  right  angle  or  even  below  that. 
Or  in  a  second  variety,  the  bend  is  at  the  epiphyseal  line  between 
head  and  neck.  The  former  is  more  common  in  childhood. 
Symptoms  may  not  attract  attention  in  the  presence  of  more  marked 
rickety  deformities.  There  is  limp,  single  or  double,  as  the  de- 
formity is  unilateral  or  bilateral,  with  shortening,  elevation  of  the 
trochanter,  limitation  of  abduction,  inward  rotation  and  flexion ; 
and  increase  of  outward  rotation  and  extension.  In  the  bilateral 
type  if  the  femoral  neck  is  turned  backward,  lumbar  lordosis  is 
diminished,  if  forward  lordosis  is  increased. 

Treatment  is  in  general  that  of  rachitis.  Locally,  support, 
transferring  the  weight  to  the  perineum  unless  the  pelvis  is  soft. 
Forcible  abduction  with  fixation  in  plaster  in  that  position  may 
help  correct  the  deformity,  or  at  least  stretch  the  adductors.  In 
extreme  cases  of  the  first  form,  Whitman's  operation — the  re- 
moval of  a  wedge  of  bone  directly  opposite  the  trochanter  minor. 


RICKETY  DEFORMITIES 


197 


leaving  the  cortical  substance  on  the  inner  side  of  the  bone,  with 
abduction,  bending  the  shaft  upon  the  neck  to  normal  position  and 
fixing  with  plaster  spica  for  three  months. 

RICKETY  DEFORMITIES  OF  ARM  AND  FOREARM 

Weightbearing  during  the  sitting  and  creeping  period  of  in- 
fancy, and  muscular  action,  may  bend  the  humerus,  though  seldom 
to  a  degree  requiring  treatment.  If  necessary  the  humerus  should 
be  straightened,  by  accurate,  careful  osteotomy  through  an  incision, 
avoiding  injury  to  nerves  and  vessels. 

Bowing  in  the  forearm  occurs  much  more  frequently  and  to 
greater  degree  than  in  the  arm,  and  is  usually  greatest  in  the  lower 
third.  It  tends  to  correct  itself  somewhat  as  the  rickets  is  recovered 
from,  yet  surgical  correction  may  be  necessary.  This  is  best  done 
by  osteotomy,  and  results  are  satisfactory. 

Rachitic  enlargement  at  the  wrist  joint  often  remains  noticeable 
and  unsightly  but  is  not  remediable. 

RICKETY  DEFORMITIES  OF  THE  THORAX 

Such  deformities  as  pigeon-breast,  funnel  chest,  the  flattening 
of  the  sides  of  the  thorax  from  atmospheric  pressure  and  projection 
of  its  lower  boundaries  over  the  expanded  abdomen  producing  Har- 
rison's groove,  are  not  amenable  to  any  operative  measures  or 
mechanical  appliances.  But  they  are  amenable  in  young  children  to 
general  antirachitic  treatment ;  and  they  are  especially  and  mark- 
edly benefited  (if  treated  before  the  process  of  dense  ossification 
which  follows  rickets  has  taken  place)  by  securing  a  free  flow  of 
air  through  the  upper  air  passages,  and  by  gymnastics.  Adenoids 
and  enlarged  tonsils  should  be  removed,  bronchial  and  laryngeal 
catarrhs  cured,  and  the  child  given  breathing  exercises  to  increase 
his  chest  expansion,  and  "  setting  up  "  gymnastics.  An  exaggeration 
of  the  curves  of  the  clavicle  may  occur,  but  usually  operation  is  not 
necessary.     If  one  is  undertaken  it  should  be  open  osteotomy.* 

RICKETY  DEFORMITIES  OF  THE  PELVIS 

The  rachitic  pelvis  may  yield  to  pressure,  advancing  the  pro- 
montory of  the  sacrum  and  approximating  it  and  the  acetabula  or 
tuber  ischii  which  are  fixed  below.  Thus  the  pelvis  is  narrowed  and 
distorted  so  that,  in  the  female,  later  in  life  childbearing  becomes 
dangerous  to  both  mother  and  child.  These  deformities  are  gener- 
ally not  noticed  in  children  but  their  possibility  should  be  remem- 
bered and  prevented  ])y  keeping  the  severe  case  of  rickets  horizontal 
for  a  time  ;  and  not,  by  the  use  of  braces  to  the  lower  extremities 
transferring  tlie  pressure  to  a  softened  pelvis. 

*  See  also  chapters  on  Thorax,  Spine,  and  Section  on  Rachitis.     Osteotomy 
pf  vertebrae  and  ribs  is  not  commendable. 


CHAPTER  VIII 

DISEASES   OF   PERIOSTEUM,    BONES,   AND   JOINTS 
NON-TUBERCULAR 

Acute  Periostitis — Acute  Osteomyelitis — Acute  Epiphysitis 
(Acute  Arthritis  of  Infants) — Syphilitic  Diseases  of 
Bones,  Periosteum,  Joints  and  Cartilages — Traumatic 
Arthritis — Gonococcus  Arthritis — Chronic  Secondary 
Infective  Osteo- Arthritis — Non-Inflammatory  Arthrop- 
athies— Osteo- Arthritis — Rheumatoid  Arthritis — ^Joinx 
Changes  in  Hemophilia — Ankylosis,  Arthroplasty  (20). 

ACUTE  PERIOSTITIS 

It  is  to  be  remembered  that  in  most  inflammatory  diseases 
more  than  one  tissue  is  affected.  In  pleurisy  often  that  portion 
of  the  lung  adjacent  to  the  diseased  visceral  reflection  of  the  pleura 
is  involved  in  the  inflammatory  process.  Similarly,  in  periostitis 
the  pathological  changes  do  not  cease  abruptly  in  the  covering  of 
the  bone,  but  often  involve  the  bone  itself.  Bone  diseases  often 
involve  joints.  Morbid  conditions  in  epiphyses  are  extended  to 
both  joint  and  diaphysis.  Still  there  is  somewhat  of  an  anatomical 
boundary  to  justify  our  classifications. 

Acute  periostitis  may  be  non-suppurative  or  suppurative.  The 
former  results  from  slight  trauma  and  presents  the  symptoms  of 
pain,  swelling,  and,  if  the  periosteum  be  near  the  surface,  also  red- 
ness, but  no  constitutional  symptoms.  There  is  no  tendency  for 
the  disease  to  spread.  If  it  were  to  do  so,  or  to  give  rise  to  fever 
or  chill,  it  would  indicate  infection  which  would  rapidly  merge  this 
into  the  suppurative  form  of  the  disease.  Rest,  with  the  part  ele- 
vated, and  the  application  of  hot  compresses,  usually  effect  a  cure. 
But  these  measures  should  be  promptly  carried  out,  and  also  the 
employment  of  a  brisk  laxative  and  careful  dieting;  for  in  the  be- 
ginning it  is  impossible  to  foretell  whether  the  disease  will  remain 
non-suppurative  or  take  the  far  more  severe  course  of  the  sup- 
purative variety. 

Acute  Suppurative  Periostitis. — This  disease  occurs  from 
the   presence   of   infective   organisms,    generally   staphylococci    or 

198 


PERIOSTEUM,    BONES    AND    JOINTS,    NON-TUBERCULAR     199 

streptococci,  attacking  tissues  whose  vitality  is  lowered  by  trauma 
or  by  a  pre-existent  general  disease.  And  its  course  depends  a  great 
deal  upon  the  previous  condition  of  the  patient  and  whether  he  had 
recently  suffered  from  scarlet  fever,  measles,  typhoid,  or  any  other 
infection. 

Symptoms. — The  symptoms  are  like  those  of  the  onset  of  many 
infections,  chills  or  even  convulsions,  fever,  restlessness,  anorexia, 
accelerated  pulse.  Locally  there  are  pain,  tenderness,  swelling,  later 
edema,  dark  redness,  which  in  superficial  situations  of  the  perios- 
teum comes  in  a  day,  but  in  deeper  locations  not  until  the  disease  is 
more  advanced. 

The  inflammatory  process  produces  thrombotic  changes  in  the 
minute  blood-vessels  from  the  periosteum  which  enter  into  and 
nourish  the  bone,  and  an  exudation  of  serum  and  formation  of 
pus  which  lifts  the  periosteum,  denuding  the  bone  beneath.  If 
relief  be  not  quickly  obtained  by  the  easing  of  the  tension  and 
evacuation  of  the  pus,  further  stripping  of  the  periosteum  will  occur, 
with  probable  death  of  a  portion  of  bone,  and  the  tedious  process  of 
casting  off  a  sequestrum. 

Diagnosis. — The  similarity  of  the  general  symptoms  of  this 
disease  with  those  of  the  onset  of  a  great  number  of  acute  infectious 
diseases  in  infants  and  children  has  led  to  very  many  mistakes  in 
early  diagnosis,  especially  if  the  child  is  too  young  to  draw  attention 
to  the  local  pain.  Even  when  pain  and  tenderness  are  localized 
they  are  apt  to  be  attributed  to  rheumatism  and  lead  to  delay  of  the 
proper  treatment. 

Treatment. — The  only  effective  treatment  is  by  incision  through 
the  inflamed  periosteum.  This  will  require  anesthesia  and  careful 
antisepsis.  The  fact  that  the  disease  is  an  infection  and  that  pus 
is  to  be  encountered  is  no  excuse  for  carelessness  in  risking  the 
introduction  of  additional  pathogenic  organisms.  The  incision 
should  be  free  enough  to  afford  complete  evacuation  of  the  pus  and 
will  probably  result  in  a  prompt  relief  from  the  symptoms. 

The  part  being  dressed  with  a  wet  antiseptic  compress,  and 
elevated,  the  periosteum  may  adhere  again  to  the  granulating  sur- 
face of  the  bone  and  recovery  occur  without  necrosis.  If  the 
patient  be  in  a  depraved  state  of  health,  or  if  the  periostitis  follow 
one  of  the  infectious  fevers,  convalescence  may  be  slow,  ultimate 
recovery  coming  only  after  months  of  waiting  and  a  final  seques- 
trectomy. Mild  cases  may  assume  a  subacute  or  chronic  form.  (See 
Fig.  68.) 

Osteoplastic  Periostitis  is  a  non-suppurative  disease,  very 
chronic  in  its  course.  It  is  due  to  a  continued  irritation  of  the 
periosteum,  either  locally  applied  or  from  constitutional  causes,  or 
by  local  irritation  added  to  constitutional  causes ;  not  sufficiently 


200  SURGICAL   DISEASES    OF    CHILDREN 

aggravated  to  produce  an  active  inflammation,  but  enough  to  in- 
crease the  vascularity  of  the  periosteum  and  to  excite  its  inherent 
procHvity  for  depositing  new  bone. 

This  newly  formed  bone  is  at  first  irregular  in  its  histological 
formation,  soft  and  spongy,  but  subsequently  assumes  an  approach 

to  systematic  arrangement 
of  its  canals  and  lamellae  and 
and  becomes  ossified. 

The  most  frequent  consti- 
tutional cause  of  osteoplas- 
tic periostitis  in  children  is 
hereditary  syphilis,  the  late 
manifestations  of  which 
make  their  appearance  be- 
tween the  time  of  the  sec- 
ond dentition  and  puberty, 
its  lesions  corresponding  to 
tertiary  in  the  adult.  Bony 
deposits  of  the  character  de- 
scribed appear  most  fre- 
quently upon  the  tibiae,  the 
clavicles,  and  the  bones  of 
the  forearm,  although  not 
confined  to  these  locations. 
Typical  instances  are  seen  in 
the  so-called  "  saber-leg,"  in 
which  the  anterior  surface 
of  the  tibia  becomes  convex 
from  the  increase  of  bony 
layers  beneath  the  inflamed 
periosteum. 

Bone  tumors  and  rheuma- 
toid arthritis  also  present 
occasional  examples.  Os- 
teoplastic periostitis  accom- 
panies osteitis  and  arthritis 
in  some  cases  of  tuberculo- 
sis of  the  lungs  and  empy- 
ema, and  more  rarely  in 
some  other  diseases,  and  is  sometimes  described  as  a  distinct 
complication  of  tuberculosis.  This  is  called  pulmonary  hyper- 
trophic osteo-arthropathy.  It  seems  to  be  caused  by  the  action 
of  toxins  produced  by  the  disease  which  it  accompanies.  It  in- 
volves most  frequently  the  hands,  especially  the  phalanges,  feet, 
forearms  and  legs,  producing  hypertrophy  of  the  bones  and  joints 


Fig.  68.  Periostitis  and  osteitis  of  a 
mild  type,  in  which  only  the  pyogenes 
albus  was  found.  The  disease  ex- 
tended over  months  and  required  re- 
peated sequestrectomies  and  curet- 
tings  of  different  foci.  Complete  re- 
covery.    Girl  aged  il  years. 


PERIOSTEUM,    BONES    AND    JOINTS,    NON-TUBERCULAR    201 

and  sometimes  synovial  effusions.  It  is  particularly  noticeable  in 
the  terminal  phalanges,  which  are  large  and  wide.  The  nails  are 
greatly  curved  both  longitudinally  and  transversely  and  are  coarsely 
striated,  or,  as  Fothergill  puts  it,  "  distinctly  show  they  are  only 
agglutinated  hairs."  The  pathological  process  is  one  involving  not 
only  periosteum  but  bone,  and  might  be  classified  under  either  head- 
ing. It  also  combines  osteoplastic  and  rarefactive  processes.  While 
the  deep  layers  of  the  periosteum  are  building  new  bone  upon  the 
surface  the  compact  tissue  of  the  bone  is  becoming  softened  and  ab- 
sorbed in  those  layers  next  to  the  medullary  canal.  Thus,  although 
the  bone  becomes  larger,  the  medullary  canal  also  becomes  larger. 
This  has  given  it  the  name  of  expansion  of  bone.  Although  the 
newly  formed  bone  is  somewhat  irregular  in  its  minute  formation,  the 
general  contour  of  an  affected  bone  is  preserved,  and  ossification 
proceeds  with  sufficient  rapidity  to  maintain  strength  enough  for 
use.  There  is  no  tendency  to  suppuration.  Thus  the  process  is 
quite  different  from  the  rarefactive  osteitis  in  which  not  merely 
circulating  toxins  but  bacilli  themselves  are  at  work  in  the 
bone. 

Treatment. — Treatment  is  that  of  the  constitutional  disease 
which  gives  rise  to  the  condition.  In  syphilis  full  doses  of  the 
potassium  iodide  will  be  necessary.  The  system  should  as  promptly 
as  possible  be  brought  under  the  influence  of  the  remedy,  for  the 
condition,  besides  being  painful,  especially  at  night,  and  leading  to 
deformity,  may  advance  to  destructive  instead  of  formative  changes. 
In  tuberculosis  the  local  disease  in  the  bones  will  show  the  effect 
if  improvement  takes  place  in  the  pulmonary  disease  and  in  the  gen- 
eral condition  of  the  patient,  toward  which  treatment  should  be 
directed. 

It  is  extremely  seldom  that  incisions  for  the  relief  of  tension 
will  ever  be  called  for,  even  in  the  syphilitic  form„  In  the  tubercu- 
lar this  is  never  required. 

ACUTE  OSTEOMYELITIS 

The  name  osteomyelitis  is  misleading  if  by  it  we  are  led  to 
understand  that  only  the  medulla  of  bone  is  engaged  in  the  inflam- 
matory process.  Ostitis  and  periostitis  also  are  combined  with  it; 
the  compact  lamellar  structure  being  secondarily  and  the  periosteum 
finally  involved.  Osteomyelitis  may  be  acute  or  chronic  and  the 
acute  may  be  of  two  varieties. 

Acute  Simple  Osteomyelitis  {Nonsuppurative  Myelitis)  is 
traumatic  in  its  etiology,  resulting  from  contusions  or  fractures. 
Unless  there  be  pyogenic  organisms  introduced  from  without  or 
they  be  already  present  in  the  system  at  the  time  of  the  injury,  con- 
tusions and  simple  or  even  comminuted  fractures  ordinarily  do  not 


202  SURGICAL   DISEASES    OF   CHILDREN 

give  rise  to  suppuration.  They  occasion  non-suppurative  inflam- 
mation with  its  changes  in  the  blood-vessels,  exudation  of  blood 
plasma,  emigration  of  leucocytes,  and  reparative  processes  carried  on 
by  the  cells  of  every  tissue  involved,  each  producing  and  organizing 
new  tissue  after  its  own  kind.  In  the  young  this  process  goes  for- 
ward more  rapidly  than  later  in  life,  owing  in  part  to  the  great 
vascularity  of  the  periosteum  and  the  unexpended  vitality  of  the 
cells.  Non-suppurative  osteomyelitis  may  almost  be  regarded  as 
a  physiological  process  of  repair. 

Acute  Infective  Osteomyelitis. — This  disease  is  what  the 
older  writers,  and  some  not  so  old,  called  acute  necrosis  and  attrib- 
uted to  an  infective  inflammation  of  the  periosteum — a  sub-peri- 
osteal  diffuse  phlegmonous  inflammation.  That  which  has  here  been 
described  as  periostitis  was  thought  to  have  been  located  just  outside 
of  the  periosteum,  a  parosteal  inflammation.  They  knew,  too,  that 
a  "  sub-periosteal "  periostitis  might  extend  to  the  medulla.  That 
an  inflammation  of  the  medulla  might  extend  to  the  periosteum. 
That  an  inflammation  might  begin  in  the  cancellous  portion  of  the 
epiphysis  or  in  the  epiphyseal  line  and  extend  to  the  medulla  of 
the  diaphysis.  That  an  inflammation  might  begin  in  any  one  of 
these  situations  and  extend  to  all  the  others.  Wright  refers  to  Mc- 
Namara  and  some  continental  surgeons  as  believing  that  what  he 
(Wright,  likewise  many  other  English  surgeons)  describes  as 
"  acute  periostitis  "  is  really  acute  osteomyelitis.  He  continues : 
"  This,  however,  is,  we  believe,  not  the  case  as  a  rule,  since  if  it 
were  so,  complete  recover};-  in  these  cases  without  extensive  necro- 
sis would  not  be  nearly  so  common  as  it  is.  Moreover,  in  cases  of 
acute  periostitis  dying  of  pyemia,  sections  of  the  bone  have  shown 
an  entire  absence  of  osteomyelitis  in  some  instances." 

However,  most  recent  writers  describe  this  grave  form  of 
disease  under  the  name  "  acute  infective  osteomyelitis  "  or  "  sup- 
purative osteomyelitis,"  and  all  are  agreed  as  to  its  pyogenic  origin, 
symptoms,  and  course;  and,  for  the  most  part,  as  to  its  treatment. 
It  is  the  most  serious  acute  bone  disease  occuring  at  any  time  of 
life  and  is  particularly  prevalent  in  the  young  subject  up  to  the 
seventeenth  year;  which  is  as  m.uch  as  to  say  before  ossific  union 
of  epiphysis  and  diaphysis  in  the  long  bones  has  taken  place.  It  is 
the  long  bones  of  the  extremities  which  are  most  frequently  at- 
tacked. This  illustrates  again  the  law  that  where  there  is  great 
developmental  activity  there  is  likely  to  be  great  pathological 
activity.  This  is  the  period  of  the  most  active  growth  in  length, 
which  takes  place  at  the  epiphyseal  line  in  the  long  bones.  As  is  so 
often  the  case  in  diseases  in  which  exposure  to  weather  and  to  in- 
juries plays  a  part  in  the  etiology,  males  furnish  more  cases  of 
osteomyelitis   than    females^    especially    during  youth    and    adoles- 


PERIOSTEUM,    BONES    AND    JOINTS,    NON-TUBERCULAR    203 

cence.  Slight  injury  is  more  frequently  a  determining  cause  than 
severe  injury.  It  is  most  apt  to  occur  in  those  who  have  recently 
suffered  from  one  of  the  infectious  diseases,  or  whose  general 
vitality  is  lowered  by  inheritance  or  by  an  unsanitary  manner  of 
living,  or  by  excessively  rapid  growth. 

The  infective  organisms  found  in  connection  with  this  disease 
are  staphylococci,  streptococci,  and  bacilli  in  several  varieties,  but 
all  capable  of  producing  pus ;  and  all,  as  we  know  from  study  not 
only  of  this  but  of  other  diseases,  capable  of  assuming  more  or  less 
virulent  types  in  different  cultures  of  the  same  organism  and  in 
different  patients  with  the  same  disease.  The  staphylococci  are 
represented  by  pyogenes  aureus,  albus  or  citreus.  The  staphy- 
lococcus pyogenes  aureus  heads  the  list  in  frequency.  The  pneumo- 
coccus,  the  bacillus  coli  communis  and  the  bacillus  typhosus  are 
not  rare.  The  germ  of  influenza  or  la  grippe  contributes  a  share. 
The  most  virulent  cases  are  mixed  infections  and  particularly  those 
in  which  a  streptococcus  is  present. 

Pathology. — The  inflammation  begins  in  the  newly  formed 
bone  in  close  proximity  to  the  periosteal  line.  When  the  focus  is 
immediately  beneath  the  periosteum  it  pushes  that  structure  loose 
from  its  attachment  to  the  bone.  When  the  inflammatory  seat  is 
in  the  red  marrow  of  the  cancellous  bone,  where  pus  formation  pro- 
duces great  tension,  numerous  infected  emboli  are  forced  into  veins 
and  lymphatics  and  set  up  endocarditis  or  pleuritis,  or  meningitis 
or  metastatic  abscesses  in  lungs,  brain,  kidneys,  spleen.  The  arteries 
also  in  the  inflammatory  area  become  thrombotic  and  their  blood 
supply  is  lost,  and  this,  with  the  stripping  away  of  the  swollen  and 
loosened  periosteum,  leads  to  necrosis  in  mass  of  adjacent  bone. 
The  thick  and  vascular  periosteum  of  the  child  is  very  readily  peeled 
from  the  bone,  being  only  firmly  attached  to  the  epiphyseal  carti- 
lages and  somewhat  firmly  at  tendinous  insertions.  The  extent  of 
the  destruction  is  only  limited  by  the  violence  of  the  inflammation 
and  the  length  of  time  it  is  allowed  to  go  on  without  interference, 
or  the  pus  finds  exit  by  bursting  through  the  soft  parts.  Ere  this 
occurs  the  whole  shaft  may  be  denuded  and  necrotic,  and,  loosening 
also  from  the  epiphyses,  may  lie  like  a  foreign  body  in  the  pus  sac 
composed  of  the  periosteum.  In  one  of  my  cases  the  entire  radius 
was  thus  cast  loose  and  subsequently  removed.  In  mau}^  cases  the 
destructive  changes  are  mainly  at  the  end  of  the  diaphysis,  the  perios- 
teum having  yielded  and  allowed  the  escape  of  the  abscess  contents 
into  the  soft  parts.  This,  however,  does  not  allow  of  its  escape 
externally.  Confined  still  by  fasciae,  muscles  and  skin,  dt  will  bur- 
row and  ,extend.  Again,  with  escape  of  pus  and  relief  of  tension, 
the  periosteum  may  finally  become  reattached  at  least  in  part  to 
the  bone  beneath.    But  the  infection  focus  may  have  been  originally 


204  SURGICAL   DISEASES    OF   CHILDREN 

nearer  to  the  medulla  of  the  shaft  or  may  quickly  extend  to  it  from 
the  cancellous  marrow,  setting"  up  suppuration  there.  The  in- 
flammation in  the  marrow  itself  with  the  pressure  produced  within 
its  closely  confined  space  is  thought  to  account  for  the  fatty  lemboli 
which  have  been  forced  into  the  circulation,  and  are  so  often  found 
in  the  lung's  and  elsewhere.^  If  the  inflammation  has  been  more 
central  and  has  not  caused  loosening  of  the  periosteum,  the  necrosis 
also  may  be  confined  to  the  central  portion  of  the  bone. 

If  the  patient  survives  the  toxemia  and  escapes  the  fatal  com- 
plications and  the  pus  has  found  exit  by  natural  or  surgical  means, 
there  begins  a  process  for  the  removal  of  the  necrosed  bone  or 
sequestrum.  Granulation  tissue  has  circumscribed  the  area  of  in- 
flammatory activity  and  afforded  a  degree  of  protection  to  the  rest 
of  the  system.  A  process  of  softening  and  liquefaction  of  a  portion 
of  bone  overlying  the  sequestrum  takes  place.  The  periosteum, 
if  its  inner  layers  were  not  destroyed,  has  produced  new  bone ;  and 
after  the  lapse  of  months  the  sequestrum  may  be  entirely  separated 
from  its  involucrum  which  presents  one  or  more  openings  or  sinuses 
from  which  detritus  is  continually  discharged. 

Symptoms. — The  symptoms  are  those  common  to  an  acute 
infection  of  virulent  type.  Often  the  most  alarming  symptom  is  a 
chill  or  convulsion.  In  older  children  lassitude  may  have  been  com- 
plained of  previously,  and  severe  pain.  With  the  chill  comes  high 
fever  and  by  this  time  excruciating  pain,  worse  on  movement. 
There  may  be  morning  remission  of  the  fever  and  evening  rise, 
and  this  with  delirium,  diarrhea  and  exhaustion  give  a  picture  much 
resembling  typhoid,  with  the  addition  of  pain  and  tenderness  in  the 
bone  or  bones  invohcd.  The  child  cannot  permit  a  movement  or 
touch  of  the  parts  without  agony,  and  holds  them,  involuntarily 
as  well  as  voluntarily,  fixed  by  reflex  spasm  of  the  muscles.  The 
soft  parts  over  the  diseased  bone  become  reddened  and  swollen, 
then  intensely  reddened  and  edematous.  This  whole  series  of 
phenomena  advances  with  frightful  rapidity.  In  some,  the  so- 
called  fulminant  cases,  the  septic  intoxication  is  so  overwhelming 
that  death  may  occur  within  thirty-six  hours  from  the  onset.  It  is 
not  uncommon  to  find  edema  of  a  limb  in  forty-eight  hours  and 
fluctuation  soon  after.  If  the  disease  breaks  through  into  a  joint 
the  symptoms  of  acute  purulent  synovitis  are  superadded.  If  the 
patient  survives  longer,  evidences  of  infection  metastases  may  ap- 
pear ;  septic  pneumonia,  pericarditis,  pleurisy,  meningitis,  nephritis, 
in  fact,  there  may  be  disseminated  foci  in  muscles  including  heart 
muscles,  in  almost  any  of  the  viscera,  and  not  uncommonly  pyemia. 
Enlargement  of  the  spleen  and  albuminuria  are  usual  and  do  not 
necessarily  imply  splenic  or  nephritic  inflammation.  Eruptions  or 
1  See  Peters'  very  clear  account  in  the  American  Practice  of  Surgery. 


PERIOSTEUM,    BONES    AND    JOINTS,    NON-TUBERCULAR    205 

rashes  like  those  of  many  septic  intoxications  may  appear  upon  the 
skin. 

Diagnosis. — So  many  errors  and  disastrous  delays  in  diagnosis 
of  this  disease  would  not  be  made  if  only  patients  were  invariably 
carefully  examined.  The  general  symptoms  of  the  onset  of  this 
disease  so  resemble  those  of  many  other  acute  infections  that  the 
practitioner,  after  noting  the  temperature,  pulse,  and  respiration, 
and  perhaps  looking  at  the  throat,  is  apt  to  say  "  It  may  be  scarlet 
fever,  or  typhoid,  or  perhaps  only  a  spoiled  stomach.  We  can  tell 
more  certainly  in  a  day  or  two."  And  so  precious  time  is  lost.  The 
young  child  does  not  locate  pain  accurately,  and  his  cries  and  dread 
of  handling  is  perhaps  attributed  to  peevishness  or  fear  of  the 
doctor.  If  attention  is  drawn  to  pain  or  tenderness  about  a  limb, 
too  often  they  are  attributed  to  rheumatism.  If,  as  is  not  infre- 
quently the  case,  there  is  a  history  of  exposure  to  cold  or  wet,  the 
diagnosis  of  rheumatism  is  considered  proven.  As  the  scapegoats 
of  medical  pediatrics  are  teething  and  worms,  the  scapegoat  of  joint 
and  bone  surgery  in  childhood  is  rheumatism.  Mr.  Owen  has  very 
graphically  described  ^  the  evils  of  this  ready  diagnosis  of  rheuma- 
tism in  acute  infectious  osteomyelitis,  and  points  out,  what  many  a 
practitioner  would  discover  if  he  only  took  pains  to  examine,  that 
the  swelling  is  in  the  shaft  of  the  bone  (albeit  near  the  epiphysis), 
whereas  in  rheumatism  it  would  be  in  the  joint.  Moreover,  the 
joint  inflammations  of  rheumatism  are  multiple — scarcely  ever  con- 
fined to  one  joint  or  limb.  With  infectious  osteomyelitis  the  trouble 
is  usually  in  one  part,  frequently,  but  not  always,  one  extremity. 
Yet  it  should  be  borne  in  mind,  as  Peters  has  emphasized,  that  the 
occurrence  of  multiple  foci  in  osteomyelitis  should  receive  attention. 
And  he  cites  a  case  which  presented  points  of  infection  in  both 
tibiae,  both  astragali,  sixth  and  seventh  ribs,  two  points  on  spine 
of  right  scapula,  infra-spinous  fossa  of  left  scapula,  and  the  left 
pubic  ramus.  While  some  of  these  points  were,  as  he  remarks, 
probably  pyemic,  the  advice  to  examine  all  palpable  epiphyses  on 
admission  of  a  suspected  case,  and  to  watch  for  new  foci  during 
the  development  of  a  case,  is  nevertheless  good.  It  seems  hardly 
credible  that  the  skin  eruption  of  osteomyelitis  should  lead  a  prac- 
titioner to  deceive  himself  as  to  the  nature  of  the  disease,  but  it  may 
resemble  scarlet  fever  or  other  exanthem,  and  this  mistake  has 
occurred. 

Prognosis. — There  is  hardly  a  disease  of  childhood  in  which, 
for  the  saving  of  limb  or  life,  so  much  depends  upon  prompt  recog- 
nition of  the  disease  and  the  employment  of  proper  treatment.  \\'ith 
the  exception  of  the  fulminant  cases,  which,  regardless  of  treat- 
ment, inevitably  go  on  to  the  fatal  end,  it  may  be  said  that  nearly 

1  Surgical  Diseases  of   Children,  p.   365,  et   seq. 


2o6  SURGICAL    DISEASES    OF    CHILDREN 

all  cases  could  be  saved  if  treated  early.  But  that  even  the  ordinary 
cases  not  treated  will  probably  prove  fatal  and  are  certain  to  result 
in  serious  loss  of  bone,  and  many  of  them  in  spontaneous  disloca- 
tions, contractures,  sub-luxations,  ankyloses,  chronic  sinuses,  et 
cetera. 

Treatment. — The  treatment  is  surgical.  This  does  not  mean 
leeches,  fomentations,  icebags,  poultices.  It  means  the  use  of  the 
knife  in  making  prompt  incision  or  incisions  down  upon  the  dis- 
eased bone.  Yet  the  parts  should  not  be  inconsiderately  laid  open 
from  end  to  end  of  th^e  bone,  as  is  sometimes  advised.  That  makes 
an  extensive  wound  in  a  young  child;  and  the  incisions  should  be 
made  with  due  respect  for  the  vessels  and  nerves.  Even  muscles 
should  not  be  incised  if  a  safe  and  suitable  intermuscular  space  can 
be  followed  to  the  bone,  or  if  the  muscle  fibers  can  be  separated 
longitudinally  by  dry  dissection  down  to  the  periosteum,  which 
must  be  incised.  The  objects  of  the  opening  are  free  drainage  and 
relief  from  tension,  and  if  these  are  secured  the  incision  is  sufficient. 
If  there  is  evidence  that  the  disease  has  extended  beyond  the  reach 
of  the  incision  another  incision  can  be  made  lower  or  higher  to  find 
the  extreme  extent  of  the  suppurative  process.  The  area  between 
can  be  washed  out  from  one  opening  to  the  other.  It  is  necessary, 
also,  to  explore  with  drill  or  gouge  into  the  bone  itself.  Especially 
is  this  true  if  the  case  is  of  the  virulent  type  with  evidence  of  great 
toxemia  and  yet  not  enough  pus  is  encountered  on  going  beneath 
the  periosteum  to  account  for  the  general  condition.  Then  the 
bone,  even  the  medullary  cavity,  must  be  explored;  and  if  pus  be 
found  which  extends  beyond  reach,  a  counter  opening  must  be  made, 
the  same  as  the  counter  opening  in  the  soft  parts,  and  the  canal 
cleaned  between.  I  do  not  think  it  is  advisable  early  in  a  case  to 
attempt  to  open  the  entire  shaft,  or  even  the  entire  periosteum,  and 
undertake  to  remove  every  particle  of  diseased  tissue.  For  one 
reason,  I  do  not  believe  it  is  possible  to  remove  every  minute  throm- 
botic blood-vessel  or  lurking  microbe;  certainly  not  without  a 
sacrifice  of  much  sound  tissue  and  the  risk  of  opening  to  infection 
parts  not  otherwise  infected.  For  one  cannot  tell,  early  in  a  case, 
just  how  far  an  infection  has  extended. 

It  is  well  worth  while,  as  Nichols  has  pointed  out,  to  endeavor 
to  preserve  the  endosteum  as  well  as  the  periosteum.  Experience 
with  this  as  with  analogous  conditions  proves  that  when  tension  is 
relieved  and  free  drainage  afforded  there  is  comparativelv  little 
danger  of  further  absorption  of  toxines  or  of  metastases  and 
pyemia.  The  attack  of  the  enemy  is  drawn  off  by  friends  from 
without,  and  nature  relieved  can  erect  her  own  barriers.  The 
wounds  should  usually  be  dressed  moist,  at  least  at  first,  with  ample 
absorbent  dressings  while  it  is  draining.     Sandbags,  splints  or  sup- 


PERIOSTEUM,    BONES    AND    JOINTS,    NON-TUBERCULAR    207 

porting  apparatus  should  be  used.  Splint  or  other  support  is  nec- 
essary even  if  epiphysis  and  shaft  have  not  separated.  If  they  have 
separated  no  one  would  deny  their  necessity  of  support ;  but  under 
other  conditions  one  sometimes  sees  the  principle  of  rest  neglected. 
Besides  promoting  rest,  the  splint  aids  to  prevent  contractures.  It 
should  be  so  applied  that  it  need  not  be  removed  while  the  dressing 
is  made.  In  the  meantime  the  general  condition  should  receive  at- 
tention in  the  way  of  anodynes  sufficient  to  relieve  the  pain,  stimu- 
lants without  stint,  as  much  easily  assimilable  food  as  the  patient 
can  make  use  of,  and  baths,  the  ice-cap  and  hypnotics  as  required. 

There  are  some  cases  of  acute  osteomyelitis  in  which  the  ques- 
tion of  amputation  will  rise,  and  this  may  occur  at  two  different 
stages  of  the  disease.  First  in  a  very  virulent  type  of  medullary 
disease  with  thrombosis  of  the  large  vessels  of  the  limb  and  per- 
haps implication  of  a  joint.  In  such  a  case  the  danger  of  amputation 
is  very  great,  and  there  is  no  certainty  that  other  foci  of  disease  have 
not  already  been  started.  It  is  certainly  inadvisable  to  consider 
amputation  unless  thrombotic  vessels  can  be  ligated  above  any 
thrombosis. 

The  second  stage  or  condition  is  when  exhaustion  is  threatening 
from  long-continued  suppuration,  especially  if  joints  are  suppurat- 
ing or  a  whole  shaft  has  become  destroyed.  This  condition  is  rather 
more  promising  of  a  safe  operation ;  but  it  is  also  usually  more 
amenable  to  other  measures  of  relief,  such  as  excision,  curettage, 
more  thorough  irrigation. 

After  the  acute  stage  of  the  disease  has  passed  there  comes 
a  long  period  of  waiting  which  is  very  tedious  for  the  patient  and 
his  friends,  while  nature  is  endeavoring  to  separate  the  sequestrum 
from  the  bone  which  survived.  This  process  will  require  from  six 
weeks  to  three  or  four  months,  according  to  the  bone  involved,  the 
size  of  the  sequestrum  and  the  age  of  the  patient.  This  time  should 
be  used  to  improve  the  general  condition  of  the  patient  with  well- 
studied  diet,  baths,  massage,  and,  if  possible  (and  it  generally  is 
possible),  by  life  in  the  open  air  and  sunshine.  A  bed-ridden  patient 
can  be  carried  out  of  doors  upon  a  cot  or  Bradford  frame ;  many 
can  use  crutches  or  a  wheel  chair ;  af  the  trouble  is  in  the  upper 
extremity  they  can  walk  out.  Wounds  or  sinuses  should  of  course 
be  carefully  dressed  and  splints  or  braces  worn  when  necessary. 
On  account  of  the  slowness  of  nature's  methods  of  separating  the 
dead  from  the  living  bone,  many  surgeons  have  tried  to  improve 
upon  it.  Some  have  advocated  cutting  down  upon  the  dead  bone 
and  chiseling  or  gouging  it  away,  even  going  over  the  line  into  liv- 
ing bone,  and  then  closing  the  wound.  This  procedure  has  been 
applied  at  different  lengths  of  time  after  the  onset  of  the  disease, 
even  as  soon  as  the  cessation  of  the  active  illness,  or  as  lone  as  would 


2o8  SURGICAL    DISEASES    OF    CHILDREN 

almost  suffice  for  a  natural  separation  o£  the  necrosed  bone.  But 
it  is  impossible  to  precisely  define  beforehand  where  the  line  of  sepa- 
ration is  going  to  take  place.  Consequently  the  operation  is  sure 
to  result  in  a  waste  of  living  bone,  and  no  one  has  been  able  to  show 
a  result  obtained  by  surgical  interference  before  separation  of  the 
sequestrum  any  more  satisfactor}-  than  that  produced  by  nature. 
It  should  be  understood,  too,  that  natural  processes,  if  given  time 
enough,  are  capable  of  taking  care  of  the  entire  process,  not  only 
of  separating  the  dead  bone  from  the  living,  but  extruding  it  from 
the  body.  This  would  come  about,  as  before  remarked,  by  a  process 
of  osteoporosis,  a  softening  and  liquefaction  and  removal  of  a  por- 
tion of  the  living  bone  which  encircles  the  dead,  thus  creating  an 
opening  through  which  the  disintegrated  and  gradually  dissolved 
dead  bone  would  be  carried  by  the  discharges  or  crowded  out  by 
the  granulations.  The  encircling  involucrum  would  then  close  in 
and  the  construction  of  a  new  bone  very  much  resembling  the  origi- 
nal in  shape  and  of  size  natural  to  the  part  would  be  built  up.  But 
these  changes  would  occupy  months  and  years ;  and  there  is  a  stage 
at  which  surgery  can  be  of  great  assistance,  by  removing  the  seques- 
trum when  it  has  been  separated,  or  almost  separated,  from  the 
involucrum.  That  the  proper  stage  for  interference  has  been 
reached  may  be  judged  by  the  length  of  time  elapsed,  by  the 
evidence  of  the  formation  of  the  involucrum  as  shown  by  thicken- 
ing in  the  shaft,  or  as  shown  by  the  X-ray,  and  by  the  use  of  the 
probe  introduced  through  a  sinus  into  a  cloaca  of  the  involucrum. 
It  is  sometimes  possible,  if  the  sequestrum  is  entirely  loose,  to  move 
it  with  the  probe  perceptibly  to  the  sense  of  touch.  To  delay  re- 
moval of  the  sequestrum  after  it  has  separated  only  allows  time 
for  the  hardening  of  the  involucrum  into  more  dense  or  eburnated 
bone,  and  loses  the  advantage  of  the  first  vascularity  and  activity 
of  the  periosteum  present  at  three  or  four  months  after  the  necrosis. 
Sequestrectomy  should  be  performed  with  all  precautions 
against  sepsis.  The  Esmarch  tourniquet  not  only  facilitates  the 
work  by  securing  a  bloodless  field,  but  it  saves  blood,  and  often 
there  would  be,  without  it,  a  good  deal  of  "blood  lost.  In  opening 
down  to  the  bone,  sinuses  and  cloacee  should  be  utilized  as  much  as 
possible,  and  the  soft  parts,  especially  nerves,  which  are  not  easily 
reunited,  should  be  duly  respected.  The  periosteum  should  be  raised 
over  the  necessary  area  with  as  little  injury  as  possible  to  the  osteo- 
genetic  layers  of  its  under  surface.  The  edges  of  a  cloaca  are  then 
gouged  or  chiseled  or  snipped  away  with  gouge  forceps,  until  a 
sufficient  opening  is  made  to  loosen  and  extricate  at  least  a  piece 
at  a  time  of  the  sequestrum.  It  may  be  that  more  than  one  opening 
into  the  involucrum  will  be  needed,  or  a  long  slit  cut  in  it,  and  the 
sequestrum  divided  before  all  the  dead  bone  can  be  removed.     All 


PERIOSTEUM,    BONES    AND    JOINTS,    NON-TUBERCULAR    209 

openings  should  be  as  narrow  as  possible,  and  if  very  long,  a  bridge 
remaining  in  the  middle  strengthens  the  trough  of  bone  that  is  left. 
In  short,  the  surgeon  should  exert  his  mechanical  skill  to  accomplish 
his  purpose  with  as  little  sacrifice  as  may  be  of  sound  bone  or  tissue 
that  might  produce  bone.  The  sequestrum  removed,  suspicious 
pockets  or  exuberant  granulations  should  be  curetted  or  touched 
with  pure  carbolic  acid  or  hydrogen  peroxide,  all  pus,  blood,  scrap- 
ings or  spiculse  carefully  wiped  out  with  gauze.  The  cavity,  if  not 
a  large  one,  is  then  rather  firmly  packed  with  iodoform  gauze ;  if 
the  cavity  is  large,  cyanide  or  plain  sterile  gauze  is  used.  An  ample 
dressing  is  applied  and  bandaged  in  place  and  the  Esmarch  rapidly 
removed.  The  limb  is  placed  upon  a  splint,  elevated,  and  next 
dressed  in  not  less  than  two  days  nor  later  than  the  third  day.  By 
this  time  there  will  be  no  bleeding ;  and  the  wound  should  be  but 
lightly  packed  and  dressed  as  before.  In  the  course  of  a  few 
months  one  may  expect  to  have  not  only  the  wound  entirely  closed 
but  the  bone  reproduced. 

On  account  of  the  time  consumed  in  this  process  and  the  neces- 
sity of  repeated  dressing  of  this  gradually  filling  and  closing  cavity, 
many  surgeons  have  applied  their  learning  and  skill  to  devise  a 
method  for  prompt  repair  and  closure  after  sequestrectomy. 
oMethods  attempted  have  included  plastic  and  osteoplastic  plans,  and 
also  the  introduction  of  various  foreign  substances  into  the  bone 
to  occupy  the  vacant  space  or  to  become  the  framework  for  the 
building  of  new  bone.  Before  any  young  surgeon  undertakes  to  ad- 
vance the  art  along  this  line,  he  may  save  time  by  studying  the 
history  of  the  subject.  Memorable  events  were  Schede's  work  with 
blood-clot  and  the  use  of  decalcified  bone  chips  as  employed  by  the 
late  lamented  Senn,  The  great  difficulty  is  in  rendering  such  a 
cavity  absolutely  sterile.  The  substance  for  filling  the  bone  cavity 
must  be  innocuous,  and  various  metals,  plasters,  cements,  trans- 
planted living  bone,  catgut,  and  other  materials  have  been  tried. 
Von  AIosetig-AIoorhof  uses  a  mixture  of  iodoform  60  parts,  sper- 
maceti and  oil  of  sesame,  each  40  parts.  These  are  heated  in  a 
water  bath  up  to  100  degrees  C.  and  constantly  agitated  while  cool- 
ing to  prevent  the  iodoform  from  settling.  The  preparation  of  the 
bone  cavity  is  a  very  important  matter.  It  is  prepared  by  curetting, 
mopping  with  a  solution  of  formalin  i  per  cent.,  or  of  bichloride 
solution  I  to  500,  or  of  chloride  of  zinc  12  per  cent.,  or  of  carbolic 
acid  95  per  cent.,  followed  by  alcohol,  mopping  with  dry  gauze,  and 
drying  with  a  current  of  hot  air.  The  cavity  must  be  absolutely  dry 
and  sterile  or  the  result  will  be  a  failure.  The  mixture,  heated  to 
50  C,  is  poured  into  the  cavity  and  the  periosteum  sutured  over  it 
with  catgut.  Temporary  drainage  by  a  few  strands  of  catgut  is 
supplied,  or  no  drainage.    The  outer  wound  is  closed  separately  with 


210  SURGICAL   DISEASES    OF   CHILDREN 

fine  silk.  A  generous  surgical  dressing  is  applied  and  the  part  im- 
mobilized. The  first  dressing  is  left  on  from  ten  days  to  two  weeks. 
This  substance  and  method  have  certain  advantages  not  pertaining 
to  any  others  yet  tried.  One  is  that  if  it  fails  the  condition  is  not 
worse  than  before,  as  occurs  when  some  of  the  osteoplastic  plans 
are  tried.  Again,  the  substance  is  not  only  innocuous,  but  anti- 
septic, and  yet  it  is  claimed  that  iodoform  poisoning  has  never  been 
caused  by  it.  Another  advantage  is  that  it  is  gradually  absorbed 
away  and  its  place  taken  by  bone  tissue.  Excellent  results  have 
been  obtained  by  this  method  in  a  large  percentage  of  cases. 

ACUTE    EPIPHYSITIS    (ACUTE    ARTHRITIS    OF    INFANTS) 

In  1884  Thomas  Smith  published  in  the  St.  Bartholomew's  Hos- 
pital reports  a  series  of  cases  which  have  often  been  cited,  of  what 
he  called  acute  arthritis  of  infants.  It  is  now  considered  that  this 
disease  is  identical  with  what  is  called  "  acute  epiphysitis,"  "  acute 
purulent  synovitis,"  "  pyemia  of  bone,"  and  even  in  a  very  confus- 
ing way,  "  acute  osteomyelitis." 

A  study  of  cases  and  of  case  reports  would  lead  one  to  suspect 
that  a  number  of  different  diseases  are  here  grouped  as  one,  albeit 
a  number  of  different  names  have  been  used  to  designate  what  is 
supposed  to  be  the  same  disease.  An  acute  epiphysitis  begins  in 
the  epiphysis  and  may  sometimes  by  timely  interference  be  arrested 
there.  But  it  tends  quickly  to  invade  the  joint.  And  in  cases  in 
which  the  joint  is  involved  the  inflammation  may  be  severe  enough 
to  extend  through  the  epiphyseal  line  and  separate  the  epiphysis. 
The  joint  cavity  may  burst  open  or  be  evacuated  by  the  surgeon 
and  recovery  take  place  without  separation  of  the  epiphysis,  and 
with  very  little  impairment  of  function ;  or  with  separation  of  the 
epiphysis  and  so  much  damage  to  the  epiphyseal  line  that  the  bone 
never  afterward  grows  in  length ;  or  the  patient  may  die  of  toxemia 
and  exhaustion,  or  pyemia.  Even  then  the  disease  does  not  tend 
to  strip  up  the  periosteum  nor  extend  into  the  medulla  and  cause 
necrosis  of  the  shaft  like  acute  infective  osteomyelitis. 

The  cases  of  acute  arthritis  described  by  Holt  and  others  in 
which  the  gonococcus  is  found  are  cases  of  purulent  synovitis.  The 
disease  begins  in  the  joint,  not  in  the  epiphysis,  and  it  does  not  tend 
to  attack  bone.  Small  joints  rather  than  large  are  affected,  often 
a  number  of  joints  in  the  same  case,  and  the  general  symptoms 
distinctly  precede  the  local  ones.  In  cases  of  acute  epiphysitis,  as 
has  just  been  said,  the  point  of  origin  and  the  destructive  course 
are  different.  The  disease  prefers  the  largest  joints  and  the  number 
of  the  cases  diminishes  with  the  size  of  the  joints.  There  is  far 
less  frequently  more  than  one  point  attacked,  either  simultaneously 
or  in  succession,  than  in  the  gonococcus  infection;  and  the  local 
and  general  symptonis  begin  almost  together, 


PERIOSTEUM,    BONES    AND    JOINTS,    NON-TUBERCULAR    211 

Acute  epiphysitis  is  a  disease  of  infancy,  and  is  more  frequent 
and  usually  more  severe  in  early  «ifancy.  Some  writers  enumerate 
all  the  predisposing  causes  of  infectious  osteomyelitis  and  add  to 
them  syphilis  and  tuberculosis,  as  the  predisposing  causes  of  acute 
epiphysitis.  But  while  these  two  diseases  may  be  predisposing 
causes,  acute  epiphysitis  should  not  be  confounded  with  the  epiphy- 
sitis of  hereditary  spyhilis.  That  disease  may  show  great  tender- 
ness, and  even  loss  of  function,  but  no  such  swelling  or  constitu- 
tional disturbance  as  the  disease  in  question. 

Symptonis. — The  bacteriology  is  the  same  as  that  of  infectious 
osteomyelitis ;  and  the  symptoms  are  so  similar  that  differentiation 
is  sometimes  difficult.  They  are  severe  pain  and  tenderness,  fixa- 
tion of  the  joint  in  a  semiflexed  position  by  muscular  spasm,  swell- 
ing. The  surface  may  be  reddened  and  effusion  may  be  detected 
in  the  joint ;  but  these  may  not  be  perceptible  until  much  damage 
has  been  done  and  the  abscess  is  about  to  make  its  way  to  the  sur- 
face. Other  symptoms  are  fever,  sleeplessness,  or  stupor  and  pros- 
tration. But  it  may  be  detected  that  with  epiphysitis  the  tenderness 
and  sweUing  are  distinctly  in  the  situation  of  the  epiphysis  or  extend 
into  the  joint,  while  with  osteomyelitis  the  tendency  is  for  the  swell- 
ing and  tenderness  to  extend  down  the  shaft.  The  habit  before 
referred  to  of  pronouncing  all  joint  diseases  rheumatism  leads  to 
errors  in  the  detection  of  acute  epiphysitis.  But  rheumatism  is  very 
rare  at  the  age  when  this  disease  is  most  common. 

Treatment. — The  treatment  is  precisely  similar  to  that  laid 
down  for  infective  osteomyelitis,  namely,  early  incision  and  drain- 
age, and  support  of  the  patient.  If  one  could  be  sure  the  case  was 
one  of  synovitis  from  the  gonococcus  and  that  suppuration  would 
not  occur,  he  might  be  content  to  wait  a  little,  at  least  until  aspira- 
tion and  examination  of  the  fl^uid.  But  in  cases  of  true  acute  epiphy- 
sitis early  diagnosis  and  early  relief  of  tension  afford  the  only  hope 
of  saving  the  joint  or  the  usefulness  of  the  limb,  or  perhaps  the  life. 

The  gonococcus  cases  may  recover  completely.  In  other  in- 
fections there  is  apt  to  be  serious  impairment.  Those  in  which  the 
epiphysis  has  been  separated  may  become  flail  joints;  and  if  the 
epiphyseal  cartilage  is  seriously  damaged  growth  in  length  of  the 
bone  'is  stunted.  Two  incisions  are  usually  necessary  to  properly 
drain  a  joint ;  although  many  a  joint  has  been,  saved  by  one.  The 
incisions  should  be  made  at  the  most  accessible  part  of  the  joint  and 
away  from  any  nerve  trunk  or  great  vessel. 

SYPHILITIC    DISEASES    OF   BONES,    PERIOSTEUM,   JOINTS 
AND   CARTILAGES 

Pseudo-paralytic  Syphilitic  Perichondrosis  sometimes 
manifests  itself  quite  suddenly  by  the  inability  of  an  infant  to  use 
a  limb.    Upon  examination  a  rhig-like  swelling  encircles  one  of  the 


SURGICAL   DISEASES    OF    CHILDREN 


long  bones  at  the  situation  of  the  epiphyseal  cartilage.  In  some 
cases  other  epiphyseal  cartilages  will  present  similar  enlargments. 
The  annular  swellings  are  tender  on  pressure  or  motion,  and  the 
infant  refrains  from  moving  the  affected  limb.     Wasting  of  the 

muscles  makes  its  appearance.  Con-r 
firmatory  evidence  of  syphilis  may  be 
found  in  snuffles,  rashes  or  a  history 
of  them,  cranio-tabes  or  bosses.  In 
rare  cases  the  syphilitic  disease  may 
suddenly  separate  the  epiphysis  from 
the  shaft,  and  even  produce  suppura- 
tion. 

There  should  be  no  real  difficulty  in 
distinguishing  this  disease  from  infan- 
tile paralysis,  rickets,  and  scurvy, 
which  each  have  their  own  character- 
istics. The  use  of  gray  powder  or 
mercury  in  any  form  effects  a  certain 
removal  of  the  symptoms  in  the  syphi- 
litic case. 

Instead  of  epiphysitis,  or  following 
it,  osteomyelitis  or  periostitis  may  ap- 
pear and  produce  a  thickening  of  the 
shafts  as  well  as  the  epiphyses,  which 
later  ossify.  One  has  seen  what  ap- 
peared to  be  a  plastic  osteo-chondro- 
sis  result  in  such  a  change  in  size  and 
shape  of  the  articular  ends  o£  the 
bones  at  the  knee  joint  that  the  limbs 
could  not  be  fully  extended.  (See 
Fig.  69.)  After  months  of  anti-syphi- 
litic treatment  the  chronic  enlargement 
Fig  6q  Plastic  osteo-  subsided  to  the  normal.  This  condi- 
CHONDRosis.  Heredi-  tion  later  was  followed  by  partial 
tary  syphilis  The  knee  paralysis  of  one  upper  and  lower  ex- 
could  not  be  fully  extended,  f  .,  .  -i,  1  •  •  ,1 
Patient  22  months  old.           tremity  and  pupillary  paralysis  m  the 

eye  of  the  opposite  side  and  loss  of 
the  hair.  Iodide  of  potassium  in  large  doses  and  mercury  in  small 
doses  cleared  up  these  symptoms,  excepting  the  eye  paralysis, 
which  diminished  but  remains  slightly  noticeable  at  this  writing. 
Cranial  Bosses  are  rounded  elevations  upon  the  frontal  and 
parietal  bones.  They  are  supposed  to  be  produced  by  an  over- 
activity of  the  pericranium  excited  by  the  syphilitic  virus  when  the 
disease  is  inherited.  A  similar  condition  is  present  in  some  cases  of 
rickets  and  it  has  been  arsfued  that  the  bosses  are  due  to  rickets  in- 


PERIOSTEUM,    BONES    AND    JOINTS,    NON-TUBERCULAR    213 

stead  of  syphilis.  M.  Parrot,  who  first  described  the  cranial  bosses 
and  attributed  them  to  hereditary  syphilis,  considered  rickets  only 
a  manifestation  of  inherited  syphilis.  That  theory  cannot  be  main- 
tained. One  evidence  against  it  is  that  in  rickets  the  younger  chil- 
dren in  a  family  are  those  increasingly  affected,  while  in  syphilis  the 
older  children  are  more  severely  diseased  and  the  virulence  de- 
creases with  the  later  ones. 

Cranio-tabes — thin,  parchment-like  spots  in  the  occipital  and 
parietal  bones  in  the  region  of  the  lambdoidal  suture  elsewhere 
described — also  appears  in  both  syphilis  and  rickets,  and  is  more  gen- 
erally believed  to  be  evidence  of  luetic  taint ;  although  tabes  is  found 
also  in  infants  not  presenting  any  other  evidence  of  either  syphilis 
or  rickets,  but  only  malnutrition.  Syphilis  is  said  to  sometimes  pro- 
duce premature  ossification  of  the  cranial  sutures. 

Nose  and  Palate. — Disease  of  the  bones  of  the  nose  is  an 
early  manifestation  and  that  of  the  palate  and  face  with  extensive 
destruction  are  among  the  late  manifestations  of  hereditary  syphilis. 
(See  Section  on  Syphilis  in  Chapter  IV.) 

Ostitis  and  Periostitis. — A  form  of  ostitis  and  periostitis  of 
the  long  bones  is  very  characteristic,  although  seen  but  rarely  by 
comparison.  It  is  typically  presented  in  the  tibiae,  which  swell, 
become  somewhat  tender,  and  undergo  a  slow  chronic  osteoplastic 
periostitis,  especially  upon  their  anterior  aspects.  This  is  often 
accompanied  by  a  diffuse  ostitis;  and  it  is  not  impossible  for  peri- 
ostitis, the  formation  of  gumma  and  its  degeneration  resulting  in 
caries  or  necrosis,  and  for  overgrowth  of  new  bone  both  in  thickness 
and  length,  to  be  in  progress  in  the  same  bone  at  the  same  time  or 
to  alternate  in  their  activity.  Arrest  of  growth  may  result  from 
syphilitic  epiphysitis.  Syphilitic  disease  is  apt  to  give  rise  to  a 
deformity  called  saber-leg,  from  the  bowing  forward  of  the  tibia 
due  to  formation  of  layers  of  bone  beneath  the  periosteum.  Sinuses 
leading  to  carious  cavities  or  to  necrotic  areas  may  also  be  present 
in  the  same  case.     (See  also  Osteoplastic  Periostitis.) 

Syphilitic  Synovitis  may  accompany  periostitis  or  ostitis 
when  it  approaches  the  joint,  or  it  may  appear  independently  of  any 
other  lesion.  It  is  apt  to  affect  several  joints  and  to  disappear  under 
the  influence  of  iodide  and  mercury. 

Diagnosis. — There  is  not  a  great  deal  of  likelihood  in  average 
cases,  of  mistaking  between  tuberculosis  and  syphilis  if  one  look 
farther  than  the  lesions  themselves  for  the  diagnosis.  The  family 
and  personal  history  should  always  be  inquired  into,  and  often  will 
uncover  evidence  of  value.  Physical  examination  will  often  dis- 
cover otitis,  keratitis,  Hutchinson's  teeth  or  nodes  in  the  syphilitic 
case ;  or  scars  of  cold  abscesses,  strumous  glands  or  enlarged 
phalanges,  with  signs  of  visceral  complications  in  the  tubercular 


214  SURGICAL   DISEASES    OF   CHILDREN 

patient.  Both  are  chronic  diseases  of  bone,  but  with  tuberculosis 
there  is  less  tendency  to  formation  of  new  bone  or  of  necrosis,  and 
more  tendency  to  suppuration  and  to  caries  than  in  syphilis.  Pain 
more  severe  at  night  or  constant  pain  in  the  absence  of  abscess  is 
more  characteristic  of  syphilis. 

The  enlargement  of  a  new  growth  is  more  definite  in  its  outline 
and  is  more  apt  to  be  about  the  end  of  a  long  bone  than  spread 
along  a  shaft. 

With  periostitis  the  swelling  comes  more  promptly  after  the 
pain  than  with  osteomyelitis. 

Chronic  periostitis  non-syphilitic  is  not  apt  to  be  symmetrical. 

One  has  seen  a  swelling  of  three  weeks'  duration  of  the  lower 
ends  and  a  portion  of  the  shafts  of  both  femurs  in  an  infant  of  nine 
months,  which  was  very  puzzling.  There  was  tenderness,  little 
fever,  and  some  redness  upon  one  thigh.  A  history  of  continued 
artificial  feeding  and  the  age  of  the  infant,  led  to  the  use  of  anti- 
scorbutic diet,  under  which  the  thighs  promptly  improved.  This 
seemed  to  confirm  a  diagnosis  of  scurvy,  although  the  gums  were 
not  spongy,  and  although  the  frontal  bones  presented  the  appear- 
ance of  moderate-sized  bosses. 

Prognosis. — In  the  conditions  which  arise  during  infancy  the 
prognosis  is  extremely  good  if  treatment  is  instituted  early.  Even 
the  separated  epiphyses  will  reunite  and  the  local  swellings  and 
tenderness  subside.  The  later  lesions  are  more  stubborn  to  over- 
come, yet  they  yield  to  energetic  medication.  When  bone  has  been 
destroyed  before  the  nature  of  the  disease  is  discovered  or  the  treat- 
ment pushed,  it  can  never  be  reproduced. 

Treatment. — Early  symptoms  of  lues  hereditaria  yield  in  a  re- 
markable way  to  mercurial  treatment  in  any  form.  (See  Section 
on  Hereditary  Syphilis.)  The  most  available  preparations  are  gray 
powder  and  oleate,  or  blue  ointment ;  though  baths  are  particularly 
useful  when  there  are  also  skin  lesions,  and  sublimation,  or  hypo- 
dermic injection  can  be  used  in  a  very  urgent  case.  The  hypodermic 
method  seems  unnecessary,  and  being  of  no  especial  advantage  and 
painful,  I  never  employ  it. 

In  the  older  children,  that  is,  in  the  later  manifestations,  potas- 
sium iodide,  or  this  with  mercury  are  very  efficacious.  One  looks 
with  confidence  for  improvement  in  nearly  every  case  as  soon  as 
enough  of  the  medicine  has  been  used.  Large  doses  of  the  iodide 
are  sometimes  necessary,  and,  unless  the  effect  is  obtained,  the  dose 
is  gradually  increased,  up  to  the  point  of  tolerance.  When  given 
with  large  quantities  of  water  there  is  little  danger  of  gastric  de- 
rangement from  the  remedy,  and  no  fear  of  iodism  appearing  before 
the  desired  alteration  in  the  lesions. 


PERIOSTEUM,    BONES    AND    JOINTS,    NON-TUBERCULAR    21S 

TRAUMATIC   ARTHRITIS 

Traumatic  Arthritis  occurs  in  children  the  same  as  in  adults 
with  little  that  is  peculiar  to  mark  either  symptoms,  course,  or 
termination.  It  may  vary  all  the  way  from  simple  synovitis,  with 
or  without  effusion,  as  a  result  of  contusion,  to  an  acute  suppurative 
arthritis  following  a  crush,  or  a  compound  dislocation,  or  a  pene- 
trating wound  of  the  joint  with  infection.  The  symptoms  are  pain 
and  tenderness,  swelling,  altered  position,  redness  and  heat  of  the 
joint  and  muscular  tension.  The  pain  is  in  the  joint  itself  excepting 
in  the  case  of  the  hip.  Pain  is  worse  on  motion.  There  is  tender- 
ness at  certain  points.  Swelling  is  sometimes  very  prompt  and 
large,  especially  if  there  is  an  effusion.  Altered  position  almost 
always  places  the  limb  about  midway  between  flexion  and  extension, 
this  evidently  equalizing  pressure  in  all  parts  of  the  joint  and  mak- 
ing it  the  least  uncomfortable.  Redness  is  not  present  in  a  simple 
synovitis,  but  makes  its  appearance  if  acute  suppuration  takes  place. 
Redness  appearing  early  indicates  injury  of  peri-articular  struc- 
tures. Local  heat  amounting  to  one  or  two  degrees  is  present  in 
proportion  to  the  violence  of  the  inflammation. 

Muscular  tension  is  always  marked  in  a  purulent  joint  inflam- 
mation. The  fluid  effused  in  acute  synovitis  may  be  very  small  in 
amount ;  or  it  may  be  altogether  absent,  in  cases  called  "  dry 
synovitis."  The  small  amount  of  fluid  is  apt  to  be  fibrinous  and  to 
lead  to  adhesions  between  the  articulating  surfaces,  thus  causing 
fibrous  ankylosis.  Fever  is  not  a  necessary  accompaniment  of 
simple  synovitis ;  but  if  suppuration  ensue  fever  of  three  or  five  or 
more  degrees  will  be  present.  Moderate  fever  may  be  present  from 
absorption  of  effused  blood  in  or  about  a  joint,  but  this  will  subside 
in  two  or  three  days. 

Diagnosis. — The  diagnosis  is  not  difficult  when  the  history  is 
known  and  the  symptoms  are  at  all  definite.  There  may  be  difficulty 
in  deciding  whether  an  enlargement  in  the  situation  of  a  deep  joint 
is  an  inflammatory  exudate  or  fluid  within  the  joint.  In  superficial 
joints  a  fluid  would  fluctuate.  Then  there  may  be  a  question  as  to 
whether  simple  effusion  or  suppuration  is  present.  The  amount  of 
fever  and  constitutional  disturbance  is  an  index ;  also  the  amount  of 
muscular  tension.  If  necessary,  tapping  with  antiseptic  precautions 
may  be  resorted  to  for  diagnosis. 

Prognosis. — Prognosis  is  somewhat  better  in  children  than  in 
adults.  One  has  several  times  been  able  to  verify  the  statement  of 
Volkmann  and  Krause  that  even  purulent  synovitis  does  not  invari- 
ably impair  the  joint  permanently  if  the  pus  finds  a  quick  exit  or 
is  promptly  removed. 

Treatment. — The   treatment   of   acute   simple   inflammation   is 


2i6  SURGICAL   DISEASES    OF   CHILDREN 

the  same  as  in  the  adult,  namely,  elevated  position,  rest,  the  ice-bag 
or  cooling  and  astringent  lotions  in  the  acute  stage;  counter  irri- 
tants, blisters,  cautery,  massage,  sometimes  aspiration  or  hyperemia 
in  the  later  stages  and  for  removing  the  products  of  inflammation. 
If  pus  is  present  in  the  joint  it  must  be  promptly  and  freely  opened 
and  drained.  An  acute  traumatic  arthritis  may  merge  into  a  chronic 
condition. 

One  important  point  in  the  treatment  of  traumatic  arthritis 
is  the  prevention  of  deformity.  An  injured  joint  should  always,  if 
possible,  be  put  up  in  the  position  in  which  it  will  be  most  useful 
if  ankylosis  takes  place.  The  hip,  knee,  and  ankle  should  be  in  the 
position  for  walking,  the  elbow  at  a  right  angle  and  with  the  wrist 
half  way  between  pronation  and  supination.  But,  if  possible, 
ankylosis  should  be  prevented  and  function  restored  by  passive 
movements  begun  as  soon  as  the  inflammation  has  subsided  enough 
to  allow  it.  There  is  nothing  to  be  gained  by  attempting  motion  in 
an  injured  joint  so  early  that  it  is  irritated  to  an  exacerbation  of 
the  inflammation.  But  a  degree  of  pain  and  temporary  soreness 
is  to  be  expected  during  and  after  the  passive  motion,  and  should 
not  prevent  its  repetition  a  day  or  two  later.  Massage  and  hot 
douches  are  very  useful  in  restoring  function  to  the  joint. 

Arthritis  of  Infective  Origin,  Non-Tubercular, — Non- 
Syphilitic. — There  is  a  class  of  cases  of  arthritis  occuring  in 
the  course  of  or  following  the  infectious  diseases,  for  instance, 
typhoid  fever,  scarlet  fever,  variola,  measles,  mumps,  dysentery, 
diphtheria,  gonorrhoea.  It  will  not  be  necessary  to  devote  much 
space  to  any  or  all  of  these,  yet  they  have  a  definite  place  in  the 
surgery  of  childhood.  For  example,  of  thirty-five  cases  collected 
by  Keen,  of  dislocations  of  the  hip- joint  in  arthritis  following 
typhoid  fever,  thirty-two  were  under  twenty  years,  and  twenty-two 
were  under  fifteen  years  of  age;  and  a  large  majority  of  the  cases 
occurring  in  connection  with  the  exanthemata  are  in  children. 
Keen  ^  analyses  the  collected  cases  of  typhoid  arthritis  under 
rheumatic  typhoid  arthritis,  septic  typhoid  arthritis,  and  typhoid 
arthritis  proper. 

The  ordinary  joint  inflammation  occurring  in  the  course  of 
scarlet  fever  is  often  called  scarlatinal  rheumatism.  It  is  unfortunate 
that  the  name  rheumatism  cannot  be  substituted  by  a  more  distinc- 
tive title  when  an  arthritis  occurs  in  connection  with  a  specific  infec- 
tion. Such  conditions  might  well  be  called  toxic  or  irritative  in 
these  secondary  cases  designated  as  rheumatic,  which  present  pain, 
tenderness  and  sometimes  synovial  effusion.  The  causative  factor 
appears  to  be  the  toxines  developed  by  the  primary  disease  without 
the  presence  in  the  joint  of  any  discoverable  organism.    The  second 

^  "  Surgical  Complications  and  Sequellse  of  Typhoid  Fever." 


PERIOSTEUM,    BONES    AND    JOINTS,    NON-TUBERCULAR    217 

class  of  cases  which  occur  in  typhoid,  scarlet  fever,  and  the  other 
primary  infections,  are  well  called  septic  or  suppurative,  for,  even 
if  they  begin  sometimes  apparently  as  serous  inflammations,  they 


Fig.  70. 

1 

P 

,— 

r 

^^     X       ^^-^ 

w 

„ 

/" 

r 

K,,^ 

\- 

'  W 

r 

i 
\ 

Fig.  71. 

Figs.  70  and  71.  Post-scaelatinal  poly-articular  arthritis  affecting  the 
right  elbow,  both  hips  and  the  right  knee.  The  right  hip  had  been  dis- 
located during  the  height  of  the  efifusion,  and  had  never  been  reduced. 

cause   suppuration   in  the   joint  or   joints   affected,   and   pyogenic 
bacteria  are  found  in  the  joint. 


2i8  SURGICAL   DISEASES    OF   CHILDREN 

There  may  be  a  distinct  third  class,  such,  for  example,  as  Keen 
considered  in  connection  with  typhoid  as  "  typhoid  arthritis  proper," 
in  which  the  joint  affection  is  caused  by  the  organism  of  the  pri- 
mary disease  alone,  unmixed  with  the  strepto-  or  staphylococcus, 
and  producing  a  slow  but  large  distension  of  the  joint,  without 
tendency  to  suppuration  or  ankylosis,  but  with  a  considerable  danger 
of  dislocation  of  the  joint. 

Whatever  the  minute  pathology  of  these  cases,  clinical  experi- 
ence records  their  occurrence  not  only  after  typhoid  but  after  the 
exanthemata.  Figs.  70  and  71  are  from  photographs  of  a  boy  of 
eight  years  who  was  brought  to  the  City  Hospital,  Cleveland,  with 
a  post-scarlatinal  poly-articular  arthritis  affecting  the  right  elbow, 
both  hips,  and  the  left  knee.  The  right  hip  had  been  dislocated 
during  the  height  of  the  effusion,  and  had  never  been  reduced.  The 
joints  were  so  tender  as  to  preclude  any  examination  without 
anesthesia,  and  the  boy  was  as  helpless  and  pitiable  as  could  be 
imagined.  He  was  also  developing  tuberculosis.  The  joint  condi- 
tions of  these  unfortunate  cases  are  apt  to  be  overlooked  during  the 
height  of  the  primary  illness,  the  general  state  of  the  patient  being 
so  serious  that  local  conditions  are  less  regarded  than  they  should 
be,  or  the  joint  regions  are  so  exquisitely  painful  as  to  forbid  a 
careful  examination,  or  they  are  considered  to  be  "  rheumatic  "  and 
requiring  only  rheumatic  medicine.  Keen  draws  attention  to  the 
fact  that  in  nearly  one-half  of  the  cases  of  dislocation  of  the  hip  in 
typhoid  the  actual  dislocation  was  the  first  fact  observed  in  con- 
nection with  the  joint,  so  insidiously  had  this  complication  ap- 
proached. 

The  inflammatory  joint  complications  need  special  attention 
wherever  located,  but  it  is  in  the  hip- joint  that  they  are  particularly 
apt  to  be  overlooked,  and  also  to  result  in  dislocation  by  decubitus 
alone  or  by  slight  accident  in  turning  or  handling  the  patient. 
Analogous  dislocations  occasionally  occur  in  rheumatism  with  large 
effusion,  and  in  adults  in  locomotor  ataxia  and  hemiplegia  where 
the  ligaments  and  muscles  are  completely  relaxed.  In  the  cases 
occurring  with  infectious  fevers  the  joint  capsule  is  gradually  com- 
pletely distended  and  relaxed  so  that  the  slightest  force  will  cause 
displacement.  In  the  case  of  the  hip- joint,  even  adduction  with 
rotation  inward,  or  with  the  shoulder  or  knee-joint,  gravity  with 
muscular  action,  will  dislocate  the  joint.  -  The  distended  condition 
of  the  joint  should  be  discovered  if  it  occurs,  and  the  limb  placed  in 
position  and  supported  in  such  manner  as  will  prevent  dislocation. 

If  dislocation  occurs  it  should  be  reduced.  This  is  usually 
effected  without  difficulty  if  attempted  early,  the  head  of  the  bone 
slipping  into  place  without  impact,  for  there  is  absence  of  muscular 
tension  or  capsular   suction.     When  easily   reduced  the  luxation 


PERIOSTEUM,  BONES  AND  JOINTS,  NON-TUBERCULAR         219 

may  easily  recur ;  and  means  should  be  used  to  guard  against  such 
an  accident.  Inflamed  joints  should  be  supported  at  rest  by  splints 
or  bandages,  slings  or  sandbags,  and  the  inflammation  allayed  by 
cold  or  hot  applications.  Aspiration  should  be  done  if  the  joint  is 
over-distended.  If  suppuration  occurs  it  should  be  incised  and 
drained.  If  ankylosed  in  dislocation,  osteotomy  and  perhaps  tenot- 
omy may  be  necessary  to  bring  the  limb  into  position  to  be  used. 

GONOCOCCUS  ARTHRITIS 

This  corresponds  to  the  usually  mono-articular  gonorrheal 
arthritis  of  the  larger  joints  in  adults;  but  is  quite  different  from 
the  pyemic  cases  alluded  to  in  the  section  on  epiphysitis.  If  merely 
irritative  as  a  result  of  toxines,  it  should  be  treated  by  rest  and 
sedatives  to  the  joint;  and  the  local  primary  infection  in  vagina, 
urethra  or  eyes  cured  as  soon  as  possible.  But  if  there  is  suppura- 
tion (which  probably  is  caused  by  the  presence  in  the  joint  of  the 
gonococcus  itself)  prompt  incision  and  drainage  should  be  resorted 
to.     Vaccines   should  be  tried. 

CHRONIC  SECONDARY  INFECTIVE  OSTEO-ARTHRITIS 

A  secondary  infective  arthritis  following  scarlet  fever  or  other 
infection  may  assume  the  character  of  an  osteo-arthritis,  and  become 
chronic.     It  should  be  treated  upon  general  principles. 

NON-INFLAMMATORY  ARTHROPATHIES 

A  number  of  diseases  could  be  grouped  under  this  heading. 
Some  are  caused  by  primary  disease  of  the  nervous  system,  such  as 
syringomyelia,  luetic  disease  of  the  posterior  columns,  tumors,  or 
injuries  of  the  spinal  cord,  myelitis,  hemiplegia,  locomotor  ataxia. 
They  are  known  as  Charcot's  joint-disease  and  are  uncommon  in 
childhood.  They  usually  present  synovitis,  with  degeneration  of 
cartilage,  ligament  and  bone  and  may  have  villous  growths  and 
osteophytes.  Dislocations  are  not  uncommon.  Other  diseases  of 
this  group  are  of  metabolic  or  of  unknown  origin.  We  have  space 
for  but  two,  osteo-arthritis  and  the  joint-changes  of  hemophilia.  * 

OSTEO-ARTHRITIS  (RHEUMATOID  ARTHRITIS) 

Marsh  writes :  "  The  old  writers  styled  the  affection  rheumatic 
gout;  Haygarth  (1805)  nodosity  of  the  joints;  Robert  Adams, 
chronic  rheumatic  arthritis ;  Garrod,  rheumatoid  arthritis.  The 
French  term  it  arthrite  seche,  or,  after  Cruveilhier,  usure  des  carti- 
lages articulaires ;  the  Germans,  arthritis  deformans.  Many  re- 
cent authorities  speak  of  it  as  osteo-arthritis,  or  monarticular 
rheumatism,  or,  when  it  is  seated  in  the  hip,  morbus  coxse  senilis. 
*  Treatment  is  by  rest,  support,  braces  and  gypsum  bandages.  Operative 
reparative  surgery  is  apt  to  be  disappointing.  Aspiration  may  be  required. 
Amputation  is  a  last  resort. 


220  SURGICAL  DISEASES    OF   CHILDREN 

So  profuse  an  assortment  of  titles  suggests  that  much  doubt  has 
existed  as  to  the  real  nature  of  the  affection  " :  Which  is  very  true ; 
and  doubt  still  exists  and  the  number  of  titles  augments.  One  of  the 
most  recent  writers  (Painter,  in  "American  Practice  of  Surgery") 
describes  it  under  the  name  atrophic  arthritis.  Thus  the  termina- 
tion "  itis  "  is  retained  and  the  disease  is  classified  under  the  non- 
tubercular  inflammations  of  joints,  although  the  article  states  that 
"  it  is  in  no  sense  an  inflammatory  disease  "  and  that  "  the  inflam- 
matory causation  theory  receives  no  positive  support  from  pathol- 
ogy, for  all  the  lesions  which,  through  any  stretch  of  the  imagi- 
nation, could  be  called  inflammatory,  are  of  such  a  chronic  nature 
that  they  might  be  caused  by  any  local  irritation,  be  it  inflam- 
matory or  otherwise."  So  we  are  not  yet  at  an  end  of  confusion 
in  our  nomenclature  and  classification.  If  one  were  to  venture  yet 
another  name  it  would  be  chondro-atrophic  arthropathy.  It  is  not 
peculiar  to  childhood  and  is  rarer  in  youth  than  in  adult  life,  yet  it 
does  occur  before  puberty.  While  occasionally  associated  with  or 
following  the  acute  infectious  diseases  or  rheumatism,  it  is  not 
thought  to  be  a  direct  result  of  either,  nor  yet  of  any  central  nerv- 
ous lesion,  but  of  some  a^  yet  unknown  disorder  of  metabolism  ac- 
companied by  an  unaccountable  loss  of  lime  salts  from  the  body, 
infiltration  of  the  synovial  tissues  and  atrophy  and  erosion  of  carti- 
lages. There  is  also  degeneration  of  bone,  but  no  caries  nor  necrosis. 
Its  course  is  extremely  chronic.  It  is  usually  poly-articular,  begin- 
ning often  in  the  phalangeal  joints,  with  spindle-shaped  swelling 
from  thickening  of  the  synovial  villi.  There  is  not  much  pain, 
slight  tenderness,  and  no  local  heat.  The  adjacent  muscles  atrophy. 
Motion  becomes  more  and  more  restricted,  and  deformity  occurs, 
usually  by  traction  of  the  flexors  upon  the  joints  whose  cartilages 
are  atrophied.  (See  Fig.  72.)  With  treatment  the  disease  can  at 
least  be  arrested  and  the  use  of  the  joints  often  considerably  im- 
proved. 

Treatment. — Nutrition  should  be  kept  up  by  a  mixed  diet  to 
the  full  capacity  of  the  digestion.  Medicine  should  comprise  such 
reconstructives  and  tonics  as  hypophosphites,  iron  and  strychnine, 
rhubarb  or  columba  and  sodium  or  potassium  bicarbonate.  Baths, 
douches,  packs  are  useful  in  all  stages.  Exercise,  passive  or  active, 
should  be  begun  after  the  acute  condition  is  over,  and  systematically 
persevered  in.  Massage  is  useful,  especially  after  the  first  stage. 
Rest  and  protection  of  the  joints  should  be  afforded  by  means  of 
splints,  which  can  be  removed  for  the  administration  of  the  water 
treatment,  the  exercise  and  the  massage,  and  then  replaced.  Braces 
can  often.be  used  to  support  the  joints  and  protect  them,  to  prevent 
deformity  and  to  a  certain  extent  to  correct  it,  while  not  interfering 
with  such  motion  as  they  are  capable  of.     When  the  treatment 


periosteum;  bones    and    joints,    non-tubercular    221 

mentioned  does  not  succeed  in  preventing  deformity  that  seriously 
impairs  function,  it  may  be  necessary  to  improve  the  position  and 
degree  of  motion  by  operative  means.  When  the  joint  is  full  of 
hypertrophied  villi,  arthrotomy  or  a  modified  erasion  may  be  re- 
sorted to,  in  a  manner  similar  to  that  described  for  fungous  tuber- 
culosis, but  less  extensive.    No  gouging  is  necessary,  but  a  thorough 


Fig.  72.    Rheumatoid  Arthritis.    Boy  17  years.    Disease  began  in  12th  year. 
Joints  have  slight  motion  only.     Patches  of  plaster  put  on  by  a  quack. 

trimming  of  the  synovial  membrance  to  free  it  of  the  villous 
growths,  and  careful  closure  of  the  synovial  capsule  and  of  the  skin; 
all  done  under  strict  antiseptic  precautions.  Adhesions  between  the 
freshly  cut  synovial  surfaces  do  not  necessarily  follow  these  opera- 
tions. With  the  increased  room  between  the  articulating  surfaces 
it  may  be  possible  to  correct  the  deformity.  If  this  cannot  be 
effected  with  a  safe  degree  of  force,  tenotomy  of  the  flexor  tendons 
may  enable  the  surgeon  to  accomplish  a  reduction.  In  long-standing 
cases  in  which  the  removal  of  joint  fringes  is  unnecessary,  forci- 
ble correction  is  performed  by  manual  strength  or  by  the  genuclast, 
without  or  with  tenotomy.  As  a  class,  these  cases  are  much  more 
favorable  for  forcible  correction  than  cases  of  ankylosis  in  dis- 
placement after  tubercular  or  other  inflammation,  for  the  reason 
that  there  are  fewer  adhesions,  less  danger  of  lighting  up  an  old 


222  SURGICAL   DISEASES    OF   CHILDREN 

inflammation  or  spreading  an  infection,  and  less  danger  of  injuring 
vessels  which  may  have  become  embedded  in  scar  tissue  in  the 
neighborhood  of  the  joint. 

JOINT  CHANGES  IN  HEMOPHILIA 

Concerning  the  peculiar  morbid  state  known  as  hemophilia, 
or  the  bleeding  disease,  see  section  on  that  subject  in  an  earlier 
chapter.  The  joint  changes  result  from  capillary  hemorrhages  of 
the  synovial  membrane,  with  swelling  and  a  low  grade  of  inflamma- 
tion. The  inflammation  produces  adhesions  which  limit  motion  in 
the  joint.  Degenerative  changes  also  take  place  in  the  cartilages 
with  fibrillation  and  atrophy.  The  articular  ends  of  the  bones  are 
lipped.  The  changes  in  the  cartilage  and  bone  are  quite  similar 
to  those  of  rheumatoid  arthritis.  The  latter  has  no  hemorrhages. 
Neither  of  them  suppurate.  The  swelling  may  come  suddenly  and 
may  be  associated  with  hemorrhage  appearing  elsewhere,  or  by 
slight  traumatism,  though  these  associated  conditions  are  often 
absent.  The  skin  may  appear  stretched  and  shining  over  the  joint, 
or  ecchymotic.  There  is  some  tenderness  about  the  joint,  pain  on 
movement,  and  local  heat.  The  swelling  and  soreness  may  slowly 
subside,  but  often  there  remains  some  permanent  impairment,  and 
recurrent  attacks. 

Diagnosis. — Any  obscure,  subacute,  relapsing  swelling  of  joints 
in  a  male  patient  should  be  viewed  with  suspicion  until  the  possi- 
bility of  hemophilia  has  been  excluded  A  family  history  of 
bleeders,  or  a  concurrent  or  previous  obstinate  hemorrhage  in  the 
patient,  or  the  presence  of  numerous  and  persistent  "  bruises  "  from 
trifling  injuries  would  set  one  right  on  the  diagnosis.  The  absence 
of  such  warning  indices  or  a  failure  to  inquire  for  them  may  lead 
to  disastrous  consequences.  Serious  and  fatal  hemorrhage  has 
occurred  from  incising,  or  tapping,  cauterizing,  and  even  blistering 
hemophiliac  joints. 

Treatment. — The  joints  should  be  placed  upon  splints,  with 
moderate  pressure  from  a  bandage,  and  an  ice  bag  applied.  Later, 
massage  and  stimulating  liniments  may  assist  in  reducing  the  swell- 
ing and  restoring  function.  The  affected  joint  should  be  very  care- 
fully used  and  protected  from  even  slight  injury.  The  internal 
treatment  will  be  found  in  the  Section  on  Hemophilia. 


CHAPTER  IX 

TUBERCULOSIS    OF    BONES    AND    JOINTS 

Bone  Tuberculosis  —  Joint  Tuberculosis  —  Tubercular  Ar- 
thritis OF  THE  Hip  (Hip-Joint  Disease;  Morbus  Coxarius; 
Articular  Ostitis  of  the  Hip) — Tuberculosis  of  the  Knee 
Joint — Tuberculosis  of  the  Ankle — Tarsal  Tuberculosis 
— Tuberculosis  of  the  Elbow  —  Tuberculosis  of  the 
Shoulder — Wrist-Joint  Tuberculosis — Sacro-Iliac  Dis- 
ease— Tubercular  Dactylitis  (Spina  Ventosa) — Tuber- 
culosis of  the  Sterno-Clavicular  Joint — Tuberculosis  of 
the  Ribs  and  their  Cartilages — Tuberculosis  of  Other 
Bones. 

These  are  the  commonest  bone  and  joint  diseases  of  childhood. 
Considering  the  chronic  course  which  they  run,  as  well  as  the  num- 
ber of  cases,  they  claim  a  great  majority  of  all  the  hours  a  surgeon 
devotes  to  bone  and  joint  surgery,  far  outnumbering  the  cases  of 
osteomyelitis,  acute  epiphysitis,  gonococcus  pyemia  and  syphilitic 
bone  and  joint  disease,  all  combined.  These  manifestations  of  tuber- 
culosis belong  to  childhood  and  youth  rather  than  to  infancy,  for 
they  seldom  appear  before  the  second  year.  The  questions  of  hered- 
ity and  of  the  predisposing  causes  have  been  dealt  with  in  a  previous 
section.  There  is  a  possibility  of  an  inherited  tuberculosis  which 
will  show  itself  in  bone.  But  there  is  a  centainty  that  an  inherited 
vulnerability  to  tuberculosis,  that  a  lowered  state  of  vitality  from 
unsanitary  living,  overcrowding,  lack  of  suitable  food  and  of  fresh 
air  and  sunlight,  and  the  effects  of  diseases,  especially  of  the  infec- 
tious diseases,  and  notably  of  measles  and  whooping-cough,  predis- 
pose the  child  to  an  attack  of  tubercular  disease  of  bone  or  joint 
just  the  same  as  they  do  to  an  invasion  of  the  viscera  or  any  other 
tissue.  However,  tuberculosis  of  bone  or  joint  may  make  its  appear- 
ance unaccountably,  where  there  is  no  known  predisposing  cause. 
Neither  is  the  atrium  of  infection  nor  any  primary  tubercular  dis- 
ease always  traceable.  There  may  previously  have  been  lymph- 
adenitis, but  quite  frequently  the  disease  of  bone  or  joint  is  the  first 
evidence  that  a  tubercular  infection  has  taken  place. 

Traumatism,  particularly  slight  traumatism,  is  frequently  an 
exciting  cause;  and  it  often  determines  the  location  of  the  disease, 
as  had  long  been  observed  clinically  before  it  was  beautifully  demon- 

223 


224  SURGICAL   DISEASES    OF    CHILDREN 

strated  experimentally  by  Schueller  and  by  Krause.  While  severe 
traumatism,  even  in  the  presence  of  tuberculosis  in  the  system  or 
introduced  at  the  time  of  the  traumatism,  does  not  increase  the 
liability  to  the  disease.  This  has  been  explained  as  being  due  to 
the  greater  effort  made  locally  by  nature  in  case  of  a  severe  injury 
than  is  made  in  case  of  a  trifling  injury. 

The  conditions  being  favorable  for  the  disease,  the  only  essen- 
tial causative  factor  is  the  tubercle  bacillus. 

BONE  TUBERCULOSIS 

Tuberculosis  may  attack  bone  of  every  class,  cartilaginous  or 
membranous ;  and  bony  tissue  of  any  type,  cancellous  or  compact ; 
or  of  any  shape  or  location.  It  prefers  cancellous  tissue;  and  its 
choice  of  location  is  the  newly-formed  immature  ossifying  tissue  in 
the  ends  of  the  long  bones,  near  the  epiphyseal  line.  In  the  short 
bones  it  locates  centrally. 

The  tuberculous  process  in  bone  is  the  same  as  in  soft  parts,  if 
we  make  allowance  for  the  different  physical  qualities  of  bone.  In 
general  miliary  tuberculosis  we  may  find,  as  a  matter  of  pathological 
interest,  miliary  tubercles  in  the  bone  marrow.  But  the  form  of 
bone  tuberculosis  which  is  present  in  surgical  disease  is  an  ostitis 
which  results  in  caries.  The  lesion  first  presents  a  grayish  center, 
surrounded  by  a  red  zone  of  congestion.  With  the  congestion  there 
is  swelling  and  infiltration,  followed  by  a  cheesy  degeneration. 
Encapsulation  may  arrest  the  disease.  Cicatrization  may  take  place 
by  the  conversion  of  em^bryonal  cells  into  connective  tissue,  or  even 
into  bone,  the  bone  around  the  cicatrized  granulating  focus  becom- 
ing sclerosed  and  forming  a  capsule.  Even  if  caseous  degeneration 
has  taken  place,  the  wall  of  the  cavity  containing  it  may  become 
cicatrized,  and  so  temporarily  sealed  in.  Or  there  may  be  softening 
of  the  area  of  inflammation,  new  foci  being  established  in  the  sur- 
rounding bone,  and  these,  in  turn,  degenerating.  Or  there  may  be 
a  proliferation  of  granulation  tissue,  which  undergoes  fatty  degen- 
eration and  produces  tuberculous  abscess,  an  irregular  carious  cavity 
in  the  bone  containing  semi-fluid  material  resembling  pus  in  appear- 
ance and  often  containing  particles  of  disintegrated  bone  or  cal- 
careous matter.  Occasionally  a  mass  of  diseased  bone  will  become 
separated  as  a  sequestrum  from  the  surrounding  bone,  but  as  a  rule 
the  process  is  one  of  caries.  Its  cavity  is  lined  with  a  "  pyogenic 
membrane."  If  the  process  of  softening,  which  always  progresses 
in  the  direction  of  the  least  resistance,  leads  to  escape  of  the  abscess 
contents  from  the  bone  into  the  surrounding  soft  parts,  we  have  a 
para-articular  abscess.  It  is  extremely  rare  for  a  tuberculous  abscess 
to  form  in  close  proximity  to  a  joint  without  a  primary  implication 
of  either  joint  or  bone. 


TUBERCULOSIS   OF   BONES    AND   JOINTS  225 

If  the  breaking  down  of  bony  tissue  extends  in  the  direction 
of  the  articular  cartilage,  and  that,  in  turn,  with  its  covering  of 
synovial  membrane,  gives  way  to  it  and  allows  the  invasion  of  the 
joint,  this  joint  abscess  may,  in  turn,  break  through  its  walls  and 
become  a  para-articular  abscess.  At  this  stage,  if  conditions  are 
favorable,  the  opening  between  bone  cavity  or  joint  cavity  and  peri- 
articular abscess  cavity  may  become  obliterated  by  processes  of 
repair,  and  cure  may  follow. 

The  abscess  outside  the  joint  may  find  its  way  by  a  compar- 
atively short  route  to  the  surface.  But  it  follow^s  the  line  of  least 
resistance,  which  often  carries  it  between  ligaments  or  muscles, 
along  fascial  planes,  or  in  the  direction  followed  by  vessels  or 
nerves  until  it  reaches  the  skin.  (See  also  Abscess  in  Section  on 
Spinal  Caries.)  After  producing  necrosis  of  a  portion  of  skin  the 
abscess  escapes,  leaving  a  long  sinus,  which  continues  to  discharge. 
Its  lining  is  covered  with  spongy  granulations,  and  if  the  opening 
in  the  skin  temporarily  heals  over,  it  soon  bursts  out  again  and  dis- 
charges its  accumulation.  Only  in  case  of  great  improvement  in 
the  condition  of  the  patient  do  these  sinuses  heal  spontaneously. 
Usually  they  show  no  tendency  to  heal. 

JOINT  TUBERCULOSIS  (21) 

Tubercular  disease  of  a  joint  generally  begins  in  one  of  the 
bones  composing  the  joint,  although  it  may  begin  in  the  synovial 
membrane.  If  beginning  in  the  head  of  a  long  bone  it  may,  as 
before  stated,  find  its  way  through  into  the  joint  by  destroying  a 
part  of  the  articular  cartilage ;  or  it  may  emerge  at  the  margin  of 
the  epiphyseal  line,  and  in  those  articulations  whose  epiphyseal  line 
is  within  the  capsule  the  disease  is  readily  communicated  to  the 
joint.  This  nearness  of  synovial  membrane  to  epiphysis  is  clearly 
depicted  in  Figs.  73  to  "]"]  after  Power. 

When  tuberculosis  occurs  in  synovial  membrane,  Konig  found 
it  sometimes  in  the  form  of  miliary  tubercles  located  in  the  sub- 
synovial  tissue,  and  without  alteration  of  the  surface  of  the  mem- 
branes, and  without  symptoms  in  the  joint.  Or  there  may  be  a 
primary  diffuse  miliary  tuberculosis,  wath  or  without  osseous  focus 
connecting  with  the  joint.  They  may  be  small  gray  tubercles, 
located  somewhat  deeply  and  occasioning  no  symptoms ;  while  in 
other  cases,  without  granulations,  the  only  indication  of  the  exist- 
ence of  a  tubercular  joint  disease  is  a  slight  hydrops  of  the  joint. 

Tubercular  hydrops  is  produced  by  a  tuberculous  infection  of 
the  synovial  membrane,  which  gives  rise  to  a  copious  eft'usion  into 
the  joint.  The  joint  becomes  distended  with  fluid,  but  the  pain,  if 
present  at  all,  is  so  slight  that  the  patient  is  able  to  use  the  limb. 
If  the  joint  is  aspirated  and  the  fluid  drawn  off  it  resembles  normal 


226 


SURGICAL   DISEASES    OF   CHILDREN 


Fig.  T2>-    Semi-diagrammatic  section  through 

THE     RIGHT     SHOULDER     JOINT,     tO     shoW     the 

relation  of  the  synovial  membrane  to  the 
upper  epiphysis  of  the  humerus.  The 
synovial  membrane  on  the  inner  side  comes 
below  the  epiphyseal  line,  but  on  the  outer 
side  it  stops  at  the  anatomical  neck,  and 
is  separated  from  the  synovial  sheath  of 
the  biceps. — Power's  Surgical  Diseases  of 
Children. 


Fig.  74.  Vertical  section 
through  the  elbow 
JOINT,  showing  the  rela- 
tion of  the  synovial  mem- 
brane to  the  lower  epiphy- 
sis of  the  humerus,  and 
the  upper  epiphysis  of  the 
ulna.  Semi-diagrammatic 
after  a  drawing  made  by 
Mr.  John  Hutchinson,  Jr. 
— Power's  Surg.  Dis.  Chil- 
dren. 


Fig.  75.  Semi-diagrammatic  drawing 
representing  a  section  through  the 
LEFT  HIP-JOINT  to  show  the  relation 
of  the  synovial  membrane  and  cap- 
sular ligament  to  the  epiphyses,  and 
to  the  articulating  surfaces. — Power's 
Surgical  Diseases  of  Children. 


Fig.  76.  Section  through 
THE  left  knee-joint,  to  show 
the  relation  of  the  synovial 
membrane  to  the  epiphyses  of 
the  femur  and  tibia  and  to  the 
articular  surfaces.  Semi-dia- 
grammatic drawing  from  Pow- 
er's Surgical  Dis.  of  Children. 


TUBERCULOSIS    OF   BONES    AND   JOINTS 


227 


synovial  fluid,  though  it  may  be  less  viscid  and  contain  small  shreds 
of  lymph.  Reaccumulation  of  the  fluid  rapidly  takes  place  in  the 
course  of  a  few  days.  Or  there  may  be  fibrinous  deposits  in  the 
synovia.  In  these  cases  of  hydrops  the  synovial  membrane  pre- 
sents but  little  alteration.  There  are  a  few  tuberculous  nodules 
imbedded  in  it.  The  condition  is  analogous  pathologically  to  tuber- 
cular ascites.  Later  the  synovial  membrane  becomes  thickened  and 
the  joints  assume  the  more  usual  con- 
dition presented  in  tubercular  synovi- 
tis.     (Senn.) 

Hueter  describes  a  form,  of  syno- 
vial tuberculosis  in  which  a  thin  vascu- 
lar layer  of  granulations  from  the  bor- 
der of  the  cartilage  approaches  the  cen- 
ter of  the  surface  of  the  joint  in  the 
manner  a  pannus  invades  the  cornea ; 
with  also  a  thickening  of  the  synovial 
membrane  which  encroaches  upon  the 
joint  space,  resembling  the  physiolog- 
ical pannus  of  the  embryo. 

A  common  and  characteristic  form 
of  joint  tuberculosis  is  that  described 
by  Bilroth  as  fungous  synovitis,  and 
by  Hueter  as  synovitis  hyperplastica 
granulosa.  It  is  probably  an  advanced 
stage  of  the  pannous  form.  It  afifects 
the  synovial  membrane  generally, 
which  becomes  hyperemic,  thickened, 
and  covered  with  velvety  granulations. 
The  granulation  tissue  is  abundant, 
springing  from  the  intima  of  the  syno- 
vial membrane,  and  while  resembling  the  granulations  of  an  open 
wound,  have  no  tendency  to  undergo  cicatrization.  The  tubercle 
bacilli  are  imbedded  in  the  granulations,  where  they  retard  the 
growth  of  the  young  blood-vessels  and  thus  determine  early  de- 
generation of  the  inflammatory  product. 

It  is  this  form  of  joint  tuberculosis,  in  which  the  ligaments  and 
para-articular  structures  are  early  involved,  that  the  thick  mass  of 
tissue,  somewhat  gelatinous  in  appearance,  but  more  firm,  and  con- 
taining foci  of  cheesy  degeneration,  are  produced,  and  called  clin- 
ically, "  white  swelling  of  the  joint."  Three  types  of  this  diflFuse 
synovial  tuberculosis  are  described,  varying  with  the  location  in  the 
layers  of  the  synovial  membrane  of  the  tuberculous  foci. 

Effusion  does  not  occur  in  the  pannous  nor  in  the  hyperplastic 
(  fungous)  forms  of  joint  tuberculosis.  The  tuberous  form  of  joint 
tuberculosis  described  by  Riedel  and  Konig  is  very  rare. 


Fig.  "jt.  Semi-diagram- 
matic DRAWING  OF  SECTION 
THROUGH    THE    ANKLE    JOINT 

to  show  the  relation  of  the 
synovial   membranes   to  the 

epiphyses  and  to  the  ar- 
tragalus.  —  Power's      Surg. 

Dis.    of    Children. 


228  SURGICAL   DISEASES    OF    CHILDREN 

The  rice-bodies  so  frequently  found  in  dropsical  joints,  and 
also  in  synovial  sheaths,  and  named  from  their  resemblance  in 
appearance  to  grains  of  boiled  rice,  may  be  taken  as  an  indication 
of  the  tubercular  nature  of  the  inflammation  in  the  joint.  They 
were  at  first  thought  to  be  detached  papillomatous  growths.  Their 
fibrinous  composition  seemed  to  tally  with  the  well-known  tendency 
of  tubercular  inflammation  of  joint  surface  and  tendon  sheaths. 
Yet  it  appears  that  they  may  not  be  composed  of  ordinary  fibrin, 
nor  dependent  upon  the  presence  of  villous  outgrowths  in  the  joint. 
They  may  be  developed  upon  the  surface  of  the  synovial  sheath, 
and  thence  launched  into  the  synovial  fluid.  While  not  in  every 
instance  tubercular  in  their  origin,  they  are  usually  so.  The  mi- 
croscope may  not  be  able  to  find  the  evidence,  but  inoculation  experi- 
ments will  demonstrate  the  difference. 

The  articular  cartilage  takes  no  active  part  in  a  tubercular 
inflammation  of  bone  or  joint,  at  least  not  early  in  the  process.  But 
it  may  be  completely  destroyed  by  the  action  of  granulation  tissue 
upon  it  from  the  bone  or  from  the  synovial  side,  the  destructive 
process  extending  from  the  periphery  toward  the  center. 

The  course  of  events  in  a  tubercular  inflammation  of  bone  or 
joint  may  at  any  time  be  greatly  altered  if  pyogenic  organisms 
gain  access  to  the  diseased  area.  This  is  especially  evident  in  case 
of  the  reinfection  of  a  tuberculous  abscess.  In  this  event  there  is 
great  danger  from  septic  absorption,  and  of  exhaustion  from  pro- 
fuse suppuration.  The  pyogenic  inflammation  destroys  the  barrier 
of  granulation  tissue  enclosing  the  abscess  and  allows  extension 
of  the  tuberculosis  locally,  or  a  general  tubercular  infection  with 
the  profuse  and  prolonged  suppuration,  amyloid  degeneration  of  the 
liver,  spleen,  kidneys,  and  intestinal  villi. 

Symptoms  and  Diagnosis  of  Tubercular  Bone  and  Joint  Dis- 
ease.— The  classical  signs  of  inflammation  are  considerably  modified 
when  the  inflammatory  process  is  of  a  tubercular  nature,  and 
especially  if  it  be  located  in  bone  or  joint. 

Heat. — Local  heat  upon  the  surface  is  not  perceptibly  increased. 

Pain  and  Tenderness. — Although  an  inflammation,  tubercular 
ostitis  is  so  slow  in  its  course  that  neither  tension  nor  its  conse- 
quence, pain,  are  very  marked  symptoms.  B}-  the  time  tension 
would  increase  the  bone  has  become  softened  and  yields  to  the  pres- 
sure. External  pressure,  as  in  standing  erect  with  spinal  caries,  in- 
creases the  pain.  Tbe  pain  is  dull  and  aching  and  worse  at  night. 
The  night  cries  of  children,  moaning  and  restlessness  and  grinding 
of  the  teeth  in  sleep,  while  not  pathognomonic,  always  call  for  a 
thorough  examination  for  tubercular  bone  disease.  Pain  is  not  al- 
ways felt  at  the  point  of  the  disease.  Its  localization  will  be  re- 
ferred to  later. 

Tenderness  is  closely  allied  to  pain.     It  is  a  more  constant  and 


TUBERCULOSIS   OF   BONES   AND   JOINTS  229 

reliable  symptom  than  pain.  A  tubercular  process  in  bone,  if  it 
approaches  anywhere  near  the  periosteum,  produces  a  localized 
sensitive  or  tender  spot,  which  can  be  found  if  searched  for,  and 
may  be  the  only  point  of  differentiation  between  a  tubercular  syno- 
vitis and  an  osteitis. 

Pain  in  a  tuberculous  joint  may  not  be  severe  in  daytime,  but 
when  the  child  falls  asleep  and  the  relaxed  muscles  allow  the  ulcer- 
ated synovial  surfaces  to  come  together,  sudden  pain  causes  him 
to  scream  out,  the  so-called  "  night  cries "  or  "  night  terrors." 
Yet  in  some  tuberculous  joints,  Senn  thinks  in  those  with  most 
exuberant  granulations,  there  is  very  little  pain  or  tenderness  so 
long  as  the  joint  surfaces  are  thus  protected.  But  when  the  in- 
flammatory process  has  proceeded  so  far  as  to  threaten  abscess,  the 
pain  and  tenderness  are  very  considerable  by  day,  as  well  as  by 
night,  and  will  be  greatly  increased  by  pressure  or  attempts  at 
movement. 

Szvelling. — Excepting  in  spina  ventosa  and  diffuse  osteomye- 
litis, tubercular  osteomyelitis  does  not  produce  enlargement  of  bone. 
These  are  forms  of  rarefying  osteitis  or  osteoporosis,  usually  accom- 
panied by  plastic  osteomyelitis  or  periostitis,  which  increase  the 
bulk  of  the  bone  externally.  Swelling  is  a  symptom  in  the  majority 
of  cases  of  joint  tuberculosis.  It  is  caused  by  thickening  of  the 
synovial  membrane  and  fungous  growths  from  its  surface,  or  by 
an  effusion  into  the  joint  in  diffuse  synovitis,  or  by  inflammatory 
exudate  outside  of  the  joint.  Hydrops  is  the  most  common  and 
readily  detected  symptom.  If  it  is  painless  and  recurs  after  tapping, 
it  is  characteristic.  The  penetration  of  the  capsule  by  a  tuberculous 
abscess  within  it  causes  a  diminution  of  the  swelling,  with  an 
increase  of  swelling  at  some  point  outside  the  joint.  There  is  one 
form  of  joint  tuberculosis  in  which  the  joint  is  diminished  instead 
of  swollen;  namely,  the  atrophic  synovitis  of  Volkmann.     (Senn.) 

Friction  or  crackling  sounds  in  the  swollen  joint  are  signs  of 
the  tuberous  or  dry  fungous  synovitis.  The  para-articular  swelling 
at  the  junction  of  long  bones  and  at  the  ankle  produces  a  fusiform 
swelling  that  is  quite  characteristic. 

Redness. — The  deeply  seated  and  slowly  advancing  inflamma- 
tion does  not  have  the  same  effect  upon  the  skin  as  an  acute  pyo- 
genic inflammation.  If  there  is  swelling  the  skin  is  somewhat 
stretched  and  whiter  than  normal,  with  a  few  large  blue  veins  across 
its  surface.  If  the  inflammatory  process  in  either  bone  or  joint 
advances  until  the  skin  itself  is  implicated,  it  turns  a  dark  red  or 
bluish-red  color,  and  even  after  abscess  evacuates,  the  margins  of 
the  opening  retain  this  hue. 

Flnctitation  is  present  in  hydrops  and  in  intra-articular  abscess, 
and  pseudo-fluctuation  is  present  when  the  joint  is  filled  with  fun- 
gous growths.    The  aspirating  needle  will  differentiate. 


230  SURGICAL   DISEASES    OF   CHILDREN 

Atrophy  of  Muscle  and  Bone  is  a  symptom  common  to  tuber- 
culosis of  both  bones  and  joints.  Duplay  and  Cazin  reviewed  the 
whole  subject  in  an  endeavor  to  discover  which  of  the  numerous 
theories — functional  inactivity,  mechanical  stretching,  propagation 
of  inflammation  to  the  muscles,  and  vaso-motor  changes — would 
best  account  for  the  atrophy,  and  considered  them  all  insufficient. 
In  common  with  most  authors  they  agreed  with  Vulpian  that  the 
cause  is  tropho-neurotic ;  the  irritation  of  the  ends  of  the  articular 
nerves  reflect  to  the  spinal  centers,  and  from  there  upon  the  cen- 
ters of  the  muscular  nerves.  (Senn.)  This  explains  the  rapid 
development  of  the  atrophy,  the  absence  of  the  reaction  of  degen- 
eration, and  the  simple  atrophy  found  in  the  muscles. 

Flexion  with  Tonic  Spa^sm  of  the  Muscles  is  present  and  usually 
an  early  symptom  in  all  cases  of  active  tubercular  joint  disease.  It 
is  not  present  in  tubercular  hydrops  articuli.  It  is  due  to  reflex 
irritation  of  the  nerves  of  the  articular  surfaces.  It  is  pretty  gen- 
erally accepted  that  this  reflex  neurosis  has  a  great  deal  to  do  with 
the  structural  changes,  the  atrophy  of  all  the  tissues  of  and  about 
the  joint,  partial  fibrosis  of  muscle,  and  fixation  in  malposition, 
which  occur  later. 

Shortening  and  Displacements  are  among  the  symptoms  of 
joint  tuberculosis  in  its  later  stages.  Shortening,  and  sometimes 
displacement,  were  formerly  attributed  to  destruction  of  some  part 
of  the  articulation ;  and  this  may  be  the  cause  in  some  cases.  But, 
as  before  remarked,  tropho-neurotic  changes  may  be  responsible 
for  atrophy  of  the  bones  of  an  affected  limb,  as  well  as  of  its  other 
structures,  and  shortening  can  result  without  destruction  of  bone. 

Subluxations  and  malpositions  are  due  to  muscular  contrac- 
tions while  the  joint  is  in  partial  flexion,  rotation  or  lateral  devia- 
tion. 

Differential  Diagnosis. — Tuberculosis  of  bones  and  joints  must 
be  differentiated  from  rheumatism,  from  syphilis  and  sarcoma.  The 
acute  inflammations  of  periosteum,  bones  or  joints  are  not  so  apt 
to  be  mistaken,  as  the  onset  is  more  sudden  and  severe.  Rheuma- 
tism is  poly-articular  and  is  apt  to  be  accompanied  by  endo-  or  peri- 
carditis. With  syphilis  there  is  apt  to  be  enlargement  of  the 
lymphatics  and  other  evidences  of  luetic  taint,  and  the  trouble  yields 
under  the  therapeutic  test. 

Prognosis. — The  destructive  processes  _of  tuberculosis  in  bones 
and  joints  and  the  reparative  processes  which  may  follow  are 
chronic  in  their  course,  extending  over  months  or  years,  or  some- 
times alternating  through  a  lifetime.  It  is  pretty  safe  to  assume 
that  a  child  with  bone  or  joint  tuberculosis  has  other  foci  of  the 
disease  somewhere  in  its  anatomy.  There  is  more  probability  of 
the  disease  becoming  general  in  a  child,  or  becoming  active  in  the 


TUBERCULOSIS   OF  BONES   AND   JOINTS  231 

meninges  or  elsewhere.  But  if  it  does  not  prove  fatal  through  sec- 
ondary lesions,  there  is  more  hope  of  repair  of  bone  or  joint  than 
there  would  be  in  an  adult. 

A  cured  case  of  bone  or  joint  tuberculosis  may  have  a  recur- 
rence, or  one  of  the  other  foci  may  become  active  months  or  years 
after.  Eradication  by  operation  of  a  local  lesion  in  bone  or  joint 
may  not  permanently  cure  the  patient  of  tuberculosis,  but  it  may 
prevent  further  absorption  from  that  lesion.  There  is  great  danger 
of  general  infection  resulting  from  operations  upon  tuberculous  tis- 
sues. Septic  infection  of  the  tuberculous  area  adds  greatly  to  the 
danger.  Amyloid  degeneration  of  the  liver,  spleen,  kidneys,  or 
intestinal  villi  are  of  very  grave  import.  Individual  cases  dififer 
so  widely  it  is  impossible  to  predict  in  the  beginning  what  will  be 
the  final  outcome  of  any  given  case.  Relief  from  pain,  reflex  spasm, 
tenderness  and  swelling,  with  improved  appetite  and  increasing 
weight,  are  all  favorable  indices. 

Treatment  of  tubercular  bone  and  joint  diseases  is  general  and 
local.  The  general  treatment  is  considered  in  the  general  Section 
on  Tuberculosis  in  a  preceding  chapter.  Rest  is  the  most  important 
of  the  agencies  for  local  treatment,  especially  of  diseases  of  joints. 
In  bone  diseases  it  does  not  give  such  evident  good  results,  except- 
ing in  spinal  caries.  Unrest  is  produced  by  three  factors — weight- 
bearing,  motion,  and  muscular  tension,  both  that  which  is  normal 
and  the  spasmodic  tension  excited  by  reflex  irritation. 

Rest  may  be  secured  by  lying  in  bed,  by  extension  and  counter 
extension,  sometimes  spoken  of  together  as  traction,  and  by  splints, 
which  are  means  of  fixation.  Splints  are  of  many  materials  and 
in  many  varieties.  They  are  applied  for  fixation ;  that  is,  to  pre- 
vent motion,  and  in  some  varieties  also  to  produce  traction.  In  one 
sense  a  bed  is  a  form  of  splint.  It  limits  motion  and  prevents 
weight-bearing  and  relieves  muscular  tension.  A  carious  spine, 
or  even  the  whole  skeleton,  may  be  splinted  by  a  Bradford  frame, 
or  a  wire  gauze  cuirass,  or  by  plaster  of  Paris,  or  poro-plastic  felt, 
or  a  steel  brace ;  and  the  limbs  by  plaster,  or  starch,  or  silicate  of 
soda,  or  wood,  or  steel,  et  cetera.  Traction  is  thought  by  some  to 
be  beneficial  by  pulling  apart  the  inflamed  joint  surfaces  and  so 
relieving  the  .irritation.  Others  think  it  acts  as  a  means  of  fixa- 
tion. Both  are  doubtless  right.  Traction  also  relieves  muscular 
tension  and  reflex  spasm  by  tiring  out  the  irritated  muscles  at  the 
same  time  it  does  the  work  they  were  attempting  to  do — it  prevents 
motion  in  the  joint.  Traction  has  a  further  use  in  correcting  the 
faulty  position  of  an  extremity.  It  may  be  applied  by  a  weight  or 
by  the  weight  of  the  limb  itself,  or  by  the  tension  of  a  spring  or 
other  mechanical  device.  Fixation  by  splint  has  some  efifect  to 
relieve   these,   but   more   slowly.     Splints   and   traction   in   one   or 


232  SURGICAL  DISEASES    OF   CHILDREN 

other  form  can  either  or  both  of  them  be  used  with  the  patient 
in  bed  or  out  of  bed,  as  the  case  requires.  Weight-bearing  upon 
the  lower  extremity  can  be  removed  by  raising  the  sound  Hmb  and 
using  crutches,  or  by  using  a  splint  which  takes  its  bearing  at 
the  pelvis.  When  bone  or  joint  is  secured  at  rest  it  should  be  in 
its  most  natural  position  for  its  usual  function.  The  hip,  knee,  and 
ankle  should  be  in  the  position  of  walking.  The  spine  should  have 
as  near  as  may  be  its  natural  curves.  The  elbow  should  make 
nearly  a  right  angle,  so  that  the  fingers  could  reach  the  mouth. 
These  positions  will  usually  be  found  the  easiest  to  maintain.  If 
the  limb  is  held  by  muscular  or  false  ankylosis  in  some  other  posi- 
tion it  should  at  first  be  put  at  rest  in  that  position,  but  with  sub- 
sequent adjustments  should  be  gradually  brought  to  one  that  would 
be  more  useful  if  ankylosis  were  to  take  place.  Counter-irritation 
by  blisters,  setons  and  the  like  is  no  longer  recommended.  Scott's 
dressing  of  compound  mercurial  ointment  is  still  used,  and  often 
appears  beneficial.  I  believe  its  effect  is  due  rather  to  the  pressure 
than  to  the  mercury.  The  only  counter-irritant  of  marked  power  in 
joint  tuberculosis  is  the  actual  cautery  usually  applied  with  the 
Paquelin  apparatus.  This,  I  think,  is  really  useful,  especially  if  the 
joint  is  painful.  Anesthesia  is  generally  necessary  with  children, 
though  one  has  had  boys  of  eight  or  ten  who  preferred  not  to  take 
the  anesthetic  and  bore  the  rapid  application  of  the  cautery  bravely. 
The  skin  is  rendered  aseptic  and  then  touched  with  the  button  at 
white  heat  over  a  goodly  part  of  the  swelling.  The  burn  is  then 
dressed  with  iodoform  gauze,  cotton,  and  the  part  put  up  in  a 
plaster  bandage  or  other  fixation  splint. 

Injections  of  antiseptic  or  chemical  substances  have  long  been 
in  use  in  tuberculosis  of  joints.  A  great  many  drugs  and  chemicals 
have  been  employed  with  the  idea  of  destroying  the  bacteria  or 
checking  their  development  or  of  limiting  their  action  upon  the 
tissues  or  promoting  repair  of  their  ravages.  Tincture  of  iodine, 
or  the  compound  tincture  of  iodine,  carbolic  acid  two  to  three 
per  cent.,  balsam  of  Peru  in  emulsion  with  oil  of  sweet  almonds, 
I  to  4,  and  a  .07  per  cent,  solution  sodium  chloride,  arsenious  acid 
in  the  form  of  Fowler's  solution,  corrosive  sublimate,  phosphate  of 
lime,  camphorated  napthol,  formalin  and  glycerine,  and  others  have 
been  used.  The  injections  are  made  either  in  the  cavity  of  the 
joint  or  deeply  in  the  tissues  near  the  boundaries  of  the  synovial 
membrane.  The  use  of  all  these,  excepting  formalin,  has  been  almost 
abandoned,  although  some  still  use  injections  of  iodoform  into  joint 
cavities  and  abscess  cavities,  and  a  few  use  the  chloride  of  zinc 
around  the  joint.  The  chloride  of  zinc  was  recommended  by  Lan- 
nelongue,  who  injected  it  into  the  periphery  of  the  lesions,  for  in- 
stance, in  four  or  five  points  around  the  joint,  or  in  tuberculosis  of 


TUBERCULOSIS   OF   BONES   AND   JOINTS  233 

the  lymph  nodes.  A  ten  per  cent,  solution  is  used,  under  antiseptic 
precautions,  using  half  a  drachm  or  more  at  a  sitting.  The  injec- 
tion, never  made  superficially,  is  to  be  made  deeply,  avoiding  vessels 
and  nerve  trunks  and  not  entering  the  joint. 

After  the  operation  the  part  is  bandaged,  splinted  and  elevated. 
A  considerable  reaction  follows,  with  swelling.  This  subsides  in 
a  few  days  and  a  plaster  bandage  puts  the  joint  at  rest.  The  iodo- 
form emulsion  is  injected  into  the  cavity  of  the  joint  or  tuberculous 
abscess,  the  pus  having  first  been  evacuated  with  a  trocar  and 
canula,  and  the  cavity  washed  out  with  a  3  to  5  per  cent,  solution 
of  boric  acid,  all  under  the  strictest  antiseptic  precautions.  The 
puncture  should  be  made  so  as  to  reach  the  joint  or  other  cavity 
by  the  shortest  route  possible  through  healthy  skin.  Ether  solutions 
with  iodoform  are  not  recommended.  A  10  per  cent,  emulsion  of 
iodoform  in  glycerine  or  olive  oil  is  the  best  preparation.  One  has 
usually  employed  the  glycerine  mixture  as  follows :  The  iodoform 
10  per  cent,  is  washed  in  solution  of  bichloride  of  mercury,  i  to 
2000,  the  watery  solution  decanted  and  the  iodoform  rubbed  with 
enough  alcohol  to  make  a  paste.  Seventy  per  cent,  of  glycerine, 
and  water  to  make  100  are  then  added.  The  glycerine  should  be 
boiled  previous  to  mixing.  Or  the  iodoform  in  the  proportion 
of  10  per  cent,  may  be  purified  by  mixing  with  five  per  cent,  solution 
of  carbolic  acid,  standing  forty-eight  hours,  with  occasional  shaking. 
The  carbolic  solution  is  strained  off,  and  the  iodoform  mixed  with 
the  glycerine.  Sometimes  mercuric  bichloride  i  to  2000  is  added. 
(Cheyne.)  Of  this  form  a  drachm  or  two  to  an  ounce  may  be  in- 
jected after  evacuation  and  irrigation,  at  intervals  of  one  to  two 
weeks.  The  injection  is  followed  by  swelling,  which  subsides  in  a 
few  days.  Two  or  three  injections  will  generally  show  whether 
there  is  to  be  improvement.  Improvement  will  be  shown  by 
"  diminution  of  the  contents  of  the  joint  or  abscess  at  each  tapping, 
lessening  of  the  solid  contents  of  the  fluid  and  increase  of  its  vis- 
cidity." "  Parenchymatous  and  intra-articular  medication  with  anti- 
bacillary  remedies  has  yielded  the  best  results  in  tubercular  spondy- 
litis, attended  by  abscess  formation,  and  tuberculosis  of  the  knee 
and  wrist  joints."     (Senn.) 

In  my  own  experience  the  injection  of  iodoform  emulsion  has 
appeared  more  useful  in  cold  abscess  cavities  than  in  joint  tubercu- 
losis, and  is  no  longer  used  in  joints. 

At  present  formalin  is  in  favor  for  injection  in  hydrops  articuli ; 
a  two  to  four  per  cent,  solution  in  glycerine.  It  should  never  pro- 
duce tension. 

Of  late  local  hyperemia  has  come  into  some  prominence  as  a 
therapeutic  agent  for  tuberculosis  of  bones  and  joints.  It  is  some- 
times called  the  Bier  treatment  or  the  Bier-Klapp  method,  after 


234  SURGICAL   DISEASES    OF   CHILDREN 

Prof.  Bier  of  Bonn  and  his  assistant  Klapp.  (See  Sections  on  Sep- 
ticemia and  on  Tuberculosis,  et  cetera.)  In  the  limbs  the  hyperemia 
is  induced  by  constriction.  An  elastic  woven  rubber  bandage  is  ap- 
plied around  the  limb  above  the  seat  of  the  disease.  It  need  not  be 
immediately  above  but  farther  up  if  convenient.  The  band  is  not 
applied  in  a  limited  zone,  but  rather  widely,  and  drawn  tightly 
enough  to  check  the  venous  return  somewhat,  without  interfering 
with  the  arterial  supply.  The  limb  below  the  constriction  gradually 
swells  and  becomes  reddened  and  slightly  bluish,  but  not  blue.  The 
bandage  is  left  on  for  about  an  hour  and  then  removed.  This  is 
repeated  daily.  At  no  time  should  the  application  or  its  result  be 
painful.  At  no  time  should  it  cause  coldness  or  numbness,  though 
there  may  be  slight  prickling  just  before  it  is  removed.  If  pain 
results,  the  technique  should  be  corrected.  If  with  correct  tech- 
nique there  is  pain,  the  case  is  not  suitable  for  the  method.  Extra 
warmth  may  result  from  the  proper  degree  of  hyperemia,  and  if 
it  does  it  augurs  well  for  the  result.  Cases  of  tubercular  bone  and 
joint  disease  usually  require  the  treatment  to  be  continued  for 
months,  and  it  may  be  necessary  for  a  year  or  even  more.  Occa- 
sional intermissions  of  a  week  in  the  treatment  are  found  bene- 
ficial. Joints  are  not  kept  at  rest  during  the  treatment  unless  use 
causes  pain.  If  there  is  no  pain,  patients  are  encouraged  to  use  the 
limb  moderately.  If  tuberculous  ulcers,  sinuses,  or  abscesses  are 
present  exercise  is  not  permitted.  Tuberculous  abscess  must  be 
opened,  and  the  treatment  should  not  follow  the  opening  for  a  few 
days.  Ulcers  and  sinuses  do  not  contra-indicate  the  treatment.  They 
are  benefited  by  it.  If  loose  sequestra  are  present  they  should  be 
removed ;  but  if  not  loose  they  should  not  be  disturbed.  If  a  joint 
is  markedly  hydropic  or  purulent,  or  so  disorganized  as  to  require 
resection,  treatment  by  hypermia  is  useless,  until  after  operative  in- 
terference. The  results  obtained  in  favorable  cases  are  relief  of 
pain ;  and  following  the  relief  of  pain  there  is  cessation  of  the  reflex 
muscular  spasm,  and  as  a  consequence,  the  avoidance  of  deformity 
and  the  restoration  of  mobility.  There  is  also,  it  is  claimed,  regen- 
eration of  both  soft  and  bony  tissues.  In  cases  which  show  im- 
provement the  treatment  is  continued  until  these  results  are  obtained. 
If  rest  has  been  tried  without  avail,  and  injection  and  local 
hyperemia  treatment  have  failed  to  check  the  disease,  and  in  some 
cases  which  advance  too  rapidly  to  wait  for  these  methods,  there  is 
no  choice  but  to  cut  down  upon  the  bone  or  joint  and  attempt  an 
eradication  of  the  disease.  This  is  especially  true  if  to  the  tubercular 
infection  a  pyogenic  infection  be  added,  or  if  a  tubercular  infection 
has  attacked  the  epiphyseal  line.  In  the  latter  case,  after  applying 
the  Esmarch  constrictor,  the  focus  should  be  cut  down  upon  and 
the  diseased  bone  gouged  out.     After  thoroughly   irrigating  the 


TUBERCULOSIS   OF   BONES   AND   JOINTS  235 

cavity  it  should  be  swabbed  with  solution  of  zinc  chloride  i  to  15, 
irrigated  again  with  sterile  water,  the  bone  cavity  packed  with  iodo- 
form gauze,  and  the  wound  in  the  soft  part  with  sterile  gauze. 
Dressing  is  changed  once  in  48  or  60  hours,  and  allowed  to  heal  by 
granulation. 

If  the  joint  abscess  affect  only  the  synovial  membrane  it  may  be 
sufficient  to  incise  freely,  irrigate  and  drain.  If  there  be  superficial 
disease  of  the  cartilages  or  bones  upon  the  articulating  surfaces, 
erasion  or  arthrectomy  will  be  necessary.  If  the  destruction  be 
greater,  resection  may  be  the  only  resort.  Resection  should  be  re- 
served for  cases  in  which  the  disease  has  invaded  both  joint  and 
bone  or  which  cannot  be  eradicated  without  going  into  the  joint,  and 
in  which  less  radical  methods,  such  as  erasion,  are  insufficient  or 
have  been  tried  and  failed ;  also  in  which  the  general  condition 
demands  relief  from  the  local  disease,  and  is  yet  sufficiently  good 
to  endure  a  severe  operation.  These  are  matters  of  judgment  upon 
each  case  individually. 

The  whole  tendency  of  practice  of  late  years,  in  dealing  with 
tubercular  bone  and  joint  disease  is  more  conservative  than  formerly. 
The  complete  removal  of  all  the  diseased  parts  about  the  joint,  in- 
cluding suppurating  old  sinuses  and  cavities,  will  sometimes  avoid 
amyloid  degeneration,  prevent  further  dissemination  of  toxines 
and  even  of  the  tubercular  disease  itself.  On  the  other  hand,  it  is 
often  very  difficult  to  remove  every  particle  of  diseased  tissue ;  and 
surgical  trauma  sometimes  leads  to  a  general  dissemination  of 
tuberculosis. 

Resection  should  always  be  avoided  if  possible  in  children,  or 
some  form  of  atypical  rather  than  typical  resection  be  employed. 
It  is  often  impossible  to  tell  before  the  joint  is  opened  whether  the 
operation  is  going  to  be  an  arthrectomy  or  an  atypical  or  typical 
resection. 

When  after  any  method  of  treatment  the  inflammation  in  a 
joint  has  subsided,  considerable  judgment  is  necessary  in  putting 
it  to  work  again.  Simple  inflammatory  disease  may  be  dealt  with 
more  promptly  and  the  child  given  liberty  in  a  week  or  two  after 
the  trouble  has  subsided.  But  with  tubercular  inflammation  months 
rather  than  wrecks  must  elapse  before  one  can  feel  sure  that  the 
trouble  will  not  return  with  use.  There  is  much  less  danger  of 
ankylosis  in  children's  joints  than  in  those  of  adults.  And  when, 
after  operation,  ankylosis  is  desired  the  bones  should  be  held  in 
position  for  months  and  sometimes  for  years  on  account  of  this 
tendency  to  form  a  joint. 

Different  Joints  Affected,  Different  Ages. — The  relative 
frequency  with  which  tuberculosis  affects  various  joints  and  the 
frequency  at  various  ages  are  shown  in  the  following  tables.     The 


236  SURGICAL   DISEASES    OF   CHILDREN 

first  table  is  from  Cheyne.  The  second  table  is  from  Holt,  giving 
the  number  of  cases  of  each  form  of  joint  tuberculosis  applying 
for  treatment  at  the  Hospital  for  Ruptured  and  Crippled,  New  York, 
during  ten  years. 


Hip 

Knee 

Ankle 

Tarsus 

Shoulder. . . 

Elbow 

Wrist 

Fingers. . . . 

Ribs 

Os    calcis . . 
Odd  bones. 
Spine 


First 

Second 

Third 

Fourth 

Fifth 

Decade 

Decade 

Decade 

Decade 

Decade 

30.2 

20.3 

4-8 

12.5 

29-5 

22.8 

18.2 

36.6 

6.2 

5-4 

5-9 

3.6 

3-3 

12.5 

4.6 

S-9 
1.6 

8.4 
4.8 

2-Z 

18.7 

6.7 

9.2 

6. 

13-3 

187 

.6 

8.4 

15.8 

133 

6.2 

1-5 

4.2 

2.4 

.  .  . 

1.2 

10. 

12.S 

2.6 

2.4 

2.4 

2-3 

6.7 

?>-2 

3.e 

. .  . 

12. 

15-2 

28. 

20. 

12.5 

Head  of  the  femur 146 

The   acetabulum 187 

The  femoral  neck 28 

The  trochanter    5 

The  femoral  shaft    5 

The  pelvis  above  the  joint 10 


381 

Of  the  146  cases  in  the  femoral  head  it  was  found  that — 

The  disease  was  primary  in  the  head  in  44  cases 

The  disease  was  secondary  in  the  head  in 48  cases 

The  question  was  undetermined  in 54  cases 

Of  the  187  cases  in  the  acetabulum — 

The  disease  was  primary  in 98  cases 

The  disease  was  secondary  in 49  cases 

The  question  was  undetermined  in 40  cases 

Spine    2,145  cases,  or  37.5  per  cent. 

Hip    i'937  cases,  or  34.0  per  cent. 

Knee    1,222  cases,  or  21.5  per  cent. 

Ankle  or  tarsus   255  cases,  or  4.5  per  cent. 

Elbow    71  cases,  or  1.2  per  cent. 

Wrist 50  cases,  or  0.9  per  cent. 

Shoulder    24  cases,  or    0.4  per  cent. 

Total    5^704  loo.o 


TUBERCULOSIS    OF    BONES    AND    JOINTS  237 

Tubercular  Spondylitis,  or  spinal  disease,  will  be  found 
described  in  the  Chapter  on  Diseases  of  the  Spine. 

TUBERCULAR    ARTHRITIS     OF    THE    HIP     (HIP-JOINT    DIS- 
EASE;  MORBUS    COXARIUS;   ARTICULAR   OSTITIS 
OF  THE  HIP) 

Etiology  and  Pathology. — The  general  etiological  factors  have 
already  been  discussed.  Quite  frequently  there  is  a  history  of 
trauma,  but  this  is  by  no  means  always  the  case. 

Location  of  the  primary  lesion  is  in  the  head  of  the  femur  near 
the  epiphyseal  line,  or  in  the  acetabulum,  or  in  the  synovial  mem- 
brane ;  when  the  latter,  it  is  apt  to  be  in  that  portion  of  the  mem- 
brane near  the  ligamentum  teres.  When  in  the  bone  it  is  not  invari- 
ably near  the  epiphyseal  line.  It  may  be  in  the  neck  of  the  femur. 
When  in  the  acetabulum  it  is  more  often  in  the  iliac  portion.  The 
majority  of  writers  agree  that  the  disease  most  often  begins  in  the 
acetabulum,  and  these  conclusions,  arrived  at  largely  by  post-mor- 
tems of  cases  which  went  on  to  resection  before  the  discovery  of 
the  Roentgen  ray,  have  since  been  to  a  great  degree  confirmed  by 
the  study  of  radiographs.  Konig's  statistics  are  probably  as  reli- 
able as  any  statistics ;  they  show  the  relative  frequency  of  the  point 
of  origin  as  well  as  it  could  be  judged  in  three  hundred  and  eighty- 
one  cases  which  were  severe  enough  to  go  on  to  excision. 

The  typical  disease  is  well  divided  into  three  stages.  In  the 
first  the  disease  is  in  the  bone  only,  the  joint  not  being  affected.  In 
the  second  stage  the  disease  has  penetrated  into  the  joint  and  in- 
volved its  structures  in  the  tubercular  process  and  usually  produced 
abscess.  Abscess  may  form  in  extra-articular  ostitis  and  remain 
in  proximity  to  but  outside  of  the  joint  cavity.  In  the  third  stage 
the  head  of  the  femur  and  the  ligamentum  teres  and  sometimes 
the  femoral  neck  are  absorbed  or  disintegrated,  together  with  other 
ligaments  about  the  joint,  a  portion  of  the  acetabulum,  and  often 
with  the  escape  of  the  abscess  contents  into  the  peri-articular  tissues. 

Abscesses  follow  the  line  of  least  resistance.  When  forming 
outside  of  the  joint  the  abscess  may  press  its  way  forward  and  ap- 
pear at  the  anterior  margin  of  the  tensor  vaginae  femoris,  a  very 
frequent  situation,  or  in  Scarpa's  triangle,  or  may  track  down  thfc 
thigh.  Abscess  may  form  within  the  joint,  and,  bursting  the  capsule, 
escape  through  the  cotyloid  notch  and  so  to  Scarpa's  triangle ;  or 
may  escape  posteriorly  and  burrow  beneath  the  glutei ;  or  penetrate 
beneath  Poupart's  ligament  into  the  pelvis ;  or  bvirrow  beneath  the 
sheath  of  the  psoas,  and,  reversing  the  usual  course  of  psoas  abscess, 
extend  into  the  pelvis.  When  the  disease  is  located  in  the  acetab- 
ulum it  may  extend  through  and  invade  the  interior  of  the  pelvis 
and  form  abscess  in  the  iliac  fossa,  or  escaping  through  the  sacro- 


238 


SURGICAL   DISEASES    OF    CHILDREN 


sciatic  foramen  it  may  burrow  in  the  ischiorectal  fossa.    With  disease 
in  the  acetabulum  abscess  formed  within  the  joint  may  perforate 

the    acetabulum    and    pursue    the    same 
course  as  an  abscess  originally  pelvic. 

Intra-pelvic  abscesses  from  hip-joint 
disease  have  been  known  to  discharge 
into  rectum  or  bladder,  feces  and  urine 
then  penetrating  the  joint  and  discharg- 
ing through  sinuses  upon  the  surface. 
(Marsh.) 

The  tonic  spasmodic  contraction  of 
the  muscles  about  the  joint  pressing  the 
head  of  the  femur  against  the  upper  part 
of  the  acetabulum  may  produce  absorp- 
tion of  that  portion  of  the  acetabulum 
pressed  upon,  allowing  the  femoral  head 
to  assume  a  position  higher  and  farther 
l)ack  upon  the  ilium.  A  ridge  of  new 
bone  forms  a  new  upper  margin  to  this 
"  wandering  acetabulum,"  as  it  is  called. 
The  head  of  the  femur,  or,  the  head 
being  absorbed,  what  remains  of  the 
neck,  may  become  dislodged  from  the 
acetabulum  onto  the  dorsum  ilii  or  an- 
teriorly; or  by  an  osteoplastic  repara- 
tive process  the  acetabulum  may  become 
obliterated  by  new  bone. 

Symptoms  and  Course. — A  limp  is 
usually  the  first  symptom.  This  may 
be  so  inconstant  that  it  excites  no  alarm 
for  a  long  time.  The  limp  is  apt  to  be 
worse  in  the  morning  and  pass  off  with 
exercise.  Sometimes  it  shows  more  with 
fatigue.  The  patient  keeps  the  limb 
MORBUS  COXAE,  left  side.  A  slightly  flexed  and  steps  lightly  upon  it. 
limp  is  usually  the  first  unconsciously  avoiding  movement  and 
symptom  The  patient  jarring  of  the  joint.  (See  Fig.  78.) 
keeps      the      limb      shghtly    i     ,      ^    ■.  \i       i-  •      j        .. 

flexed  and  steps  lightly  Late  m  the  case  the  limp  is  due  to  re- 
upon       it,       unconsciously   sultant  deformity. 

ja?H,;"/  of  ".rTote.  'ta  P^in  ™^y  be  an  early  symptom  It  is 
standing  the  greater  part  of  not  severe  in  the  beginning  in  the  or- 
the    weight    is    upon    the    binary  case.     But  there  are  acute  cases 

limb.      Girl    aged    5    .        1  •  •,    -^  •  1       t       4.1, 

in  which  it  IS  very  severe  early,   in  others 

the    severe    pain    comes    in    the    second 
Stage.    The  pain  may  be  referred  to  the  hip  region.    But  it  is  very 


Fig.  78.     First  stages  of 


sound 
years. 


TUBERCULOSIS    OF    BONES    AND    JOINTS  239 

common  and  characteristic  to  have  the  pain  located  in  or  about  the 
knee.  Pain  is  aggravated  by  movement  and  also  has  unaccountable 
exacerbations.  Pain  may  be  so  slight  that  it  is  scarcely  noticed  by 
the  child  and  difficult  to  locate,  or  so  severe  that  it  destroys  rest 
day  or  night  if  not  relieved.  Sometimes  it  can  be  elicited  by  pressure 
upon  the  joint  from  in  front.  Pain  produces  the  so-called  "  night 
cries  "  or  "  night  terrors."  This  phenomenon  when  present  usually 
occurs  as  soon  as  the  child  falls  into  a  sound  sleep.  He  cries  out 
suddenly  either  with  or  without  waking  up.  After  being  pacified  he 
becomes  quiet  for  a  time  and  again  cries  out,  and  sometimes  repeats 
this  at  intervals  throughout  the  night.  In  other  cases  after  once 
or  twice  screaming  he  sleeps  quietly.  This  symptom  is  caused  by  a 
sudden  re-contraction  of  muscles  which  during  waking  hours  have 
been  reflexly  contracted,  but  had  relaxed  their  tonicity  on  the  ap- 
proach of  sleep.  This  sudden  re-contraction  presses  the  hyper- 
sensitive surfaces  of  the  inflamed  joint  together  and  causes  pain. 

Attitude. — Early  in  the  disease  the  limb  is  abducted,  slightly 
flexed  and  rotated  outward.  This  position  is  instinctively  assumed 
because  it  affords  the  greatest  ease.  Flexion  relaxes  the  iliofemoral 
ligament,  abduction  relaxes  the  ligamentum  teres  and  the  upper 
portion  of  the  iliofemoral  ligament,  while  the  rotation  outward 
relaxes  the  inner  portion  of  the  ligament  and  the  posterior  portion 
of  the  capsule.  Later  in  the  disease,  and  especially  if  there  has  been 
some  destruction  of  the  head  of  the  femur  or  the  acetabulum,  or  at 
least  of  the  capsule,  the  position  of  the  limb  is  changed,  being  ad- 
ducted,  flexed  and  rotated  inward. 

These  attitudes  of  the  diseased  limb  occasion,  as  Howard  Marsh 
so  well  described,  certain  compensatory  positions.  (See  Figs.  79, 
80,  81,  82.)  With  the  limb  held  stiffly  abducted,  flexed  and  rotated, 
in  order  to  bring  legs  parallel  for  walking,  the  patient  is  obliged  to 
move  the  sound  limb  toward  the  abducted  diseased  one,  and  then 
to  stand  erect  he  must  tilt  his  pelvis  laterally.  To  bring  the  flexed 
thigh  to  the  perpendicular  he  arches  his  lumbar  spine  into  lordosis. 
This  change  incidentally  produces  an  apparent  lengthening  of  the 
diseased  limb,  which  is  discovered  to  be  only  apparent  and  not  real 
on  observing  the  position  of  the  pelvis. 

If  the  limb  is  held  stiffly  in  adduction  the  compensatory  move- 
ment is  reversed.  The  affected  side  is  raised,  the  lumbar  spine  is  con- 
cave on  the  diseased  side  and  there  is  apparent  shortening.  Actual 
lengthening  is  practically  unknown  and  actual  shortening  occurs  only 
later  in  the  disease  when  there  has  been  bony  loss  of  head  of  femur 
or  of  a  portion  of  the  acetabulum.  Whether  there  is  true  or  only 
apparent  shortening,  may  be  proven  by  the  application  of  Nclaton's 
or  of  Bryant's  test  lines.  Nelaton's  line  is  drawn  from  the  anterior 
superior  spine  of  the  ilium  to  the  most  prominent  part  of  the  tuber 


240  SURGICAL   DISEASES    OF    CHILDREN 

ischii.  The  normal  trochanter  will  touch  but  not  go  above  this  line. 
Bryant's  line  is  drawn  horizontally  outward  from  the  iliac  spines, 
and  the  distance  between  the  projection  of  this  line  vertically  to  the 
trochanter  is  compared  on  the  two  sides. 

Rigidity. — Muscular  rigidity  is  the  most  reliable  symptom  of 


Fig.  79.  Diagram  representing  the 
lower  extremity  fixed  in  abduc- 
TION. The  limb  cannot  be  brought 
parallel  with  its  fellow  without 
tilting  the  pelvis.     After  Marsh. 


Fig.  80.    Diagram  illustrating  tilt- 
ing  OF   THE   pelvis   WHEN   ABDUCTED 

LIMB  IS  BROUGHT  DOWN ;  with  ap- 
parent lengthening  of  the  diseased 
limb,  and  curvature  of  the  spine. 
After  Marsh. 


Fig.  81.  Diagram  illustrating 
lower  extremity  fixed  in  adduc- 
TION. To  bring  the  limbs  parallel 
the  diseased  side  of  the  pelvis  must 
be  tilted  up.     After  Marsh. 


Fig.  82.  Diagram  tllustrating  the 
tilting  of  the  pelvis  necessary 
FOR  WALKING  if  a  limb  is  fixed  in 
adduction.  The  result  is  apparent 
shortening  of  the  diseased  side  and 
corresponding  curvature  of  the 
spine.     After  Marsh. 


hip-joint  disease.  The  reflex  muscular  spasm  so  often  referred  to 
in  discussing  joint  diseases  is  almost  invariably  present  in  morbus 
coxae  under  all  circumstances  excepting  during  anesthesia,  or  after 
it  has  been  subdued  by  treatment  by  enforced  rest  of  the  joint.  In 
examining  a  case  brought  in  a  stage  so  early  that  only  slight  limp 
or  pain  or  possibly  both  are  present,  a  degree  of  rigidity  can  be 


TUBERCULOSIS   OF   BONES   AND   JOINTS  241 

detected.  The  patient  should  be  stripped  and  laid  horizontally  on 
the  back  upon  a  table.  All  manipulations  of  the  joint  should  be  very 
gentle,  lest  the  muscles  become  irritated  and  the  patient  also 
excited,  and  nothing  can  be  made  of  the  examination.  The  patient's 
confidence  should  be  gained  by  gentle  handling,  rotation,  flexion 
and  extension  of  the  sound  side  first.  Then  rotation  of  the  suspected 
limb  should  be  tried  before  the  other  motions,  by  rolling  it  slightly 
back  and  forth  under  the  outstretched  hand  upon  the  table.  If 
there  is  no  inflammation  the  limb  rolls  freely.  The  leg  is  then 
grasped  just  below  the  knee  and  fully  flexed  and  extended.  If 
when  th,e  limb  is  fully  extended  with  the  knee  flat  upon  the  table 
the  lumbar  spine  is  found  to  be  arched  up  from  the  surface  of  the 
table  it  is  demonstrated  that  the  pelvis  has  moved  with  the  thigh. 
If  now  the  limb  be  raised  until  the  lumbar  spine  lies  straight  upon 
the  table  the  position  of  the  limb  shows  the  degree  of  the  flexion 
of  the  thigh  upon  the  pelvis.  The  patient  is  now  laid  straight  with 
heels  together  and  it  is  observed  whether  the  pelvis  is  tilted  later- 
ally or  is  at  right  angles  with  the  spine.  If  the  pelvis  is  oblique  and 
the  crest  of  ilium  on  the  suspected  side  is  too  high,  it  shows  the 
limb  is  in  adduction ;  and  the  degree  of  the  adduction  can  be  found 
by  moving  the  limb  inward  until  the  iliac  crests  are  at  right  angles 
with  the  spine.  It  is  at  this  stage  that  one  frequently  finds  the 
patient  instinctively  making  extension  upon  the  diseased  limb  by 
placing  the  sound  foot  upon  the  other  and  pushing  down ;  or  by 
hooking  the  foot  of  the  afifected  limb  around  the  bedstead ;  or  fixing 
the  thigh  by  holding  it  in  the  hands.  If,  however,  the  pelvic  crest  is 
too  low  on  the  suspected  side  it  proves  the  limb  is  fixed  in  abduction, 
and  by  moving  it  from  its  fellow  the  degree  of  the  abduction  will 
be  seen  when  the  pelvis  comes  to  right  angles  with  the  axis  of  the 
spine.  Rotation  can  also  be  tested  by  gently  grasping  the  leg  below 
the  knee,  half  flexing  it  and  rotating  the  thigh  to  the  limit  of  its 
natural  range,  the  other  hand  being  placed  up  the  iliac  crest.  With 
a  healthy  joint  the  femoral  head  rolls  freely  in  the  acetabulum.  The 
method  of  testing  rotation  by  rolling  the  limb  on  the  table  is  more 
delicate  and  should  be  used  first.  The  degree  of  fixed  flexion  can 
also  be  tested  by  flexing  the  sound  thigh  firmly  upon  the  abdomen, 
and  by  this  means  holding  the  lumbar  spine  down  upon  the  table, 
while  the  suspected  limb  is  extended.  In  testing  for  rigidity  each 
movement  should  be  carried  to  its  extreme  range,  for  oftentimes  it 
is  only  as  the  limit  is  approached  that  any  restriction  is  evident. 

Swelling. — Swelling  should  be  examined  for  by  palpation  and 
may  be  detected  in  front  of  the  joint  or  behind  the  trochanter.  There 
may  be  very  slight  thickening  or  decided  brawny  swelling  all  about 
the  joint.  Usually  swelling  that  can  be  detected  is  evidence  of  ad' 
vanced  disease. 


242  SURGICAL    DISEASES    OF    CHILDREN 

Tenderness  may  sometimes  be  elicited  by  pressure,  but  should 
not  be  tested  for  early  in  the  examination  lest  fear  be  excited.  Jar- 
ring the  joint  by  striking  on  the  heel  is  of  no  practical  value. 

Atrophy. — Muscular  atrophy  is  a  very  constant  symptom,  and, 
after  rigidity,  the  most  unmistakable.  It  is  most  easily  seen  in  the 
flattening  of  the  gluteal  and  upper  thigh  muscles,  with  consequent 
partial  effacement  of  the  gluteal  fold,  or  the  fold  may  appear  single 
instead  of  double.  It  can  also  be  detected  by  grasping  the  thighs  and 
observing  the  flabbiness  of  the  wasted  one ;  and  by  spanning  its  cir- 
cumference with  the  fingers  and  thumb ;  or  by  comparative  meas- 
urements with  a  tape-measure  of  the  circumference  of  the  two  thighs 
at  corresponding  points. 

Shortening. — An  advanced  case  coming  for  examination  may 
show  marked  adduction,  with  actual  shortening,  the  acetabulum 
having  traveled  upward  upon  the  ilium,  or  more  perceptibly  the 
head  and  neck  of  the  femur  having  been  disintegrated  or  absorbed. 
In  such  a  case  abscesses  may  be  found  about  the  joint,  or  sinuses 
which  have  discharged  abscesses,  or  the  scars  resulting  from  such 
sinuses  if  they  have  healed. 

Abscess. — Abscess  may  be  found  in  a  case  only  a  few  weeks 
advanced ;  but  usually  abscess  does  not  develop  for  several  months 
after  the  onset.  Abscess  is  much  more  apt  to  occur  in  cases  which 
have  not  been  treated  or  have  been  unskillfully  treated ;  and  yet 
they  will  occur  in  some  cases  in  spite  of  the  most  prompt  and  skill- 
ful treatment.  If  an  abscess  is  small  and  deeply  seated  it  may  be 
difficult  to  find,  or  to  distinguish  from  brawny  swelling;  but  an 
abscess  of  any  size  or  not  in  the  depths  about  the  joint  may  be 
readily  detected  on  palpation  as  a  circumscribed  swelling  which 
fluctuates.  Tuberculous  abscess  is  generally  a  "  cold  abscess  "  com- 
ing with  very  little  warning  of  its  approach.  There  may  be  tender- 
ness on  pressure  as  well  as  swelling  and  fluctuation  at  a  definite 
point.  But  occasionally  abscess  of  hip  disease  comes  acutely,  or  is 
heralded  by  increase  of  the  pain  on  movement,  by  elevated  temper- 
ature, and  by  night  terrors  which  subside  as  soon  as  the  abscess  has 
pointed  and  discharged.  In  examining  for  abscess  and  for  aceta- 
bulum disease  digital  exploration  per  rectum  should  never  be  omitted. 

Atnyloid  Disease. — In  examining  any  case  in  which  suppura- 
tion is  or  has  been  present,  enlargement  of  the  liver  or  spleen  and 
albuminuria  should  always  be  looked  for.  While  rare  without 
long  and  exhausting  suppuration,  it  may  occur  sooner  than  ex- 
pected ;  while  in  other  cases  when  the  history  would  lead  one  to 
anticipate  it  no  such  degeneration  takes  place. 

The  typical  S3'mptoms  are  a  pale,  waxy  skin,  emaciation,  with 
enlarged  liver  and  spleen,  and  albuminous  urine  having  normal  or 
Ipw  specific  gravity.     Later  there  is  general  anasarca  beginning  in 


TUBERCULOSIS    OF    BONES    AND   JOINTS  243 

the  eyelids  in  the  morning.  Sometimes  diarrhea,  which  it  is  often 
impossible  and  indeed  dangerous  to  stop,  and  sometimes  nausea, 
dizziness  and  other  evidences  of  uremic  poisoning. 

Diagnosis  is  usually  made  readily  enough  if  one  has  a  clear 
idea  of  the  symptomatology  and  of  the  methods  of  examination. 
Yet  there  are  conditions  under  which  it  is  difficult  to  demonstrate 
and  a  few  other  diseases  which  may  simulate  this  disease  or  present 
some  of  its  symptoms.  In  incipient  cases  the  symptoms  may  be  very 
slight  or  inconstant.  The  pain  may  be  present  only  occasionally ; 
the  lameness  evanescent ;  the  muscular  spasm  may  be  confused  with 
voluntary  movements ;  the  thickening  over  the  joint  so  slight  as  to 
be  scarcely  distinguishable  in  a  fat  child.  Pain  referred  to  the 
knee  while  no  tenderness  or  impairment  of  the  knee  can  be  dis- 
covered is  always  mentioned  as  a  symptom  of  hip  disease,  and  yet 
similar  pain  may  be  produced  by  sacro-iliac  disease,  caries  of  the 
lumbar  spine,  or  pelvic  abscess  independent  of  any  joint  disease. 
It  has  been  stated  that  muscular  rigidity  is  the  most  constant  and 
reliable  symptom  of  hip-joint  disease,  and  this  is  true.  Yet  flexion 
and  extension  may  be  interfered  with  in  disease  about  the  upper 
end  of  the  femur  which  does  not  approach  the  joint ;  or  extension 
may  be  limited  in  psoas  or  pelvic  abscess  from  spinal  caries,  or 
appendicitis ;  flexion  may  be  checked  by  gluteal  abscess,  or  inflam- 
mation from  causes  independent  of  the  joint. 

There  should  be  no  difficulty  in  excluding  congenital  disloca- 
tion of  the  hip  notwithstanding  the  deformity. 

Acute  inflammations  are  excluded  by  their  acuteness  although 
otherwise  the  symptoms  are  similar.  All  the  acute  infections  of 
bone  or  joint  should  be  borne  in  mind  and  excluded  before  the  diag- 
nosis of  tubercular  coxitis  is  decided  upon. 

Sacro-iliac  disease  has  no  symptom  in  common  but  the  limp 
unless  abscess  occur.  The  location  of  the  disease  can  be  found  if 
sought  for. 

Simple  inflammation  from  slight  injury  of  or  about  the  joint 
may  subside  and  merge  into  a  tubercular  inflammation. 

Hysterical  joint  disease  is  very  uncommon ;  but  when  it  does 
occur  the  pain  complained  of  is.  quite  severe,  can  be  elicited  by 
slight  touches  as  well  as  firmer  pressure,  and  the  muscular  rigidity 
is  lacking  when  the  patient's  attention  is  diverted. 

A  difficult  class  of  cases  to  form  an  opinion  upon  are  those 
which  first  present  themselves  after  having  had  some  treatment 
resulting  in  a  disappearance  of  the  symptoms — whether  only  tem- 
porarily or  permanently  it  is  impossible  to  say. 

It  is  only  in  very  exceptional  cases  that  anesthesia  is  of  any 
advantage  in  examination.  For  instance,  an  advanced  case  was  sent 
to  me  with  a  diagnosis  of  bony  ankylosis.    I  considered  the  fixation 


244  SURGICAL  DISEASES    OF   CHILDREN 

due  to  tonic  muscular  contraction;  and  anesthesia  readily  made  the 
demonstration.  One  should  be  extremely  careful  of  manipulations 
under  anesthesia.  The  guardian  muscles  being  relaxed,  damage 
may  be  done. 

If  there  is  a  suspicious  history  of  occasional  lameness  or  pain, 
or  if  there  is  slight  restriction  of  freedom  of  one  of  the  movements 
of  the  joint,  but  not  enough  to  make  a  positive  diagnosis,  it  is  still  not 
safe  to  say  the  case  is  not  incipient  hip-joint  disease.  Such  a  case 
should  be  kept  under  observation. 

Prognosis. — The  mortality  from  hip- joint  disease  directly  is 
about  five  per  cent.  The  mortality  from  all  causes  directly  or  in- 
directly traceable  to  the  disease  or  to  the  tuberculosis  which  produced 
the  disease  is  twenty-five  per  cent.  The  causes  of  death  are  exhaus- 
tion from  prolonged  suppuration  with  or  without  amyloid  disease, 
tubercular  meningitis,  general  tuberculosis  or  phthisis.  Ultimate 
recovery  of  the  limb  cannot  be  certainly  promised  in  any  case.  The 
course  of  treatment  will  surely  require  one  year  and  may  take  two 
to  four  years  or  more.  Complete  recovery  of  the  limb  is  possible  if 
proper  treatment  is  instituted  early  and  thoroughly  carried  out.  In 
other  cases  the  recovery  is  practically  complete,  as  only  slight  lame- 
ness results  from  a  little  shortening  or  a  trifling  stiffness  of  the  joint 
which  is  partly  compensated  by  increased  mobility  of  the  pelvis  and 
spine.  Motion  in  the  joint  without  lameness  may  possibly  occur 
even  after  suppuration  in  the  joint.  But  this  is  not  to  be  expected, 
for  it  is  usual  to  have  shortening  and  limitation  of  motion  after 
suppuration,  and  the  shortening  may  amount  to  a  fraction  of  an  inch 
or  several  inches.  Ankylosis  may  vary  from  a  slight  limitation  of 
some  of  the  motions  to  complete  ankylosis.  On  the  other  hand, 
lameness  from  shortening  may  result  without  suppuration,  from 
damage  to  the  epiphyseal  line  of  growth,  and  shortening  from  this 
cause  may  increase  the  lameness  with  growth  of  the  other  limb. 
Muscular  atrophy  does  not  entirely  disappear. 

Treatment. — The  treatment  of  hip-joint  disease  is  constitutional 
and  local.  The  constitutional  treatment  is  that  of  tuberculosis  and 
has  been  discussed  elsewhere.  Local  treatment  is  mechanical  or 
operative.  As  was  stated  in  the  general  discussion,  the  first  great 
principle  in  the  treatment  of  joint  diseases  is  rest.  It  remains  to 
choose  the  best  means  for  securing  rest  to  this  joint.  As  to  the 
choice  between  traction  and  fixation,  there  are  many  differing 
opinions.  I  am  well  aware  that  cases  have  done  well  with  traction 
applied  by  other  methods  and  also  with  fixation  alone ;  but  after 
trying  different  means  and  methods  in  my  own  cases  and  observing 
the  results  in  other  men's  cases  my  preference  is  for  traction  at  the 
beginning  of  the  treatment.  In  the  typical  case,  with  pain  and 
muscular  spasm,  the  patient  will  be  made  comfortable,  the  tonic 


TUBERCULOSIS   OF   BONES   AND   JOINTS  245 

contraction  of  the  muscles  subdued,  the  inflammation  controlled 
more  promptly  and  efficiently  by  traction  than  by  any  other  method 
of  treatment.  And  the  traction  at  this  stage  is  best  applied  with  the 
patient  horizontally  in  bed,  by  means  of  the  weight  and  pulley, 
usually  described  as  Buck's  extension. 

Traction  applied  in  this  manner,  besides  securing  rest,  and  re- 
lieving pain  and  muscular  tension,  at  the  same  time  and  by  the  same 
means  overcomes  deformity.  I  believe,  too,  the  rest  in  bed  is  of 
advantage  at  this  stage  just  as  it  is  to  any  tubercular  patient  who 
is  carrying  an  elevated  temperature  and  losing  weight.  This  is  a 
point  not  always  considered  in  this  light,  yet  it  does  present  an  addi- 
tional advantage,  not  merely  in  traction,  but  in  traction  applied  in 
this  manner.  The  room  the  patient  is  to  occupy  should  be  the  bright- 
est and  airiest  in  the  house.  The  bed  should  be,  if  possible,  one  that 
can  be  moved  into  the  sunshine  by  the  window  or  carried  out  of 
doors  in  warm  weather.  The  mattress  should  be  firm  and  level  and 
the  springs  sufficiently  strong  to  remain  level  with  the  patient  in 
bed,  or  should  be  stiffened  with  a  board  or  slats  to  prevent  sagging. 
The  pillow,  if  any  is  used,  should  be  small.  Every  surgeon  is 
familiar  with  Buck's  extension  applied  with  a  strip  of  adhesive  plas- 
ter two  or  three  inches  wide  at  each  side  of  the  thigh,  meeting  at  a 
spreader  a  few  inches  beneath  the  foot,  and  connected  with  a  cord 
running  over  a  pulley  to  a  weight  that  hangs  down  at  the  foot  of 
the  bed.  Before  applying  the  adhesive  plaster  the  skin  should  be 
carefully  washed  with  soap,  followed  by  antiseptic  solution  as  if 
preparing  for  operation,  and  the  plaster  passed  over  an  alcohol 
flame.  If  the  plaster  is  thus  carefully  applied  it  can  be  kept  on 
several  months  without  irritating  the  skin.  The  adhesive  strap 
should  begin  well  up  on  the  thigh,  but  the  strapping  below  the  knee 
should  be  lined  with  a  strap  equally  wide  with  its  non-adhesive  side 
next  to  the  surface  of  the  leg,  so  that  traction  is  made  only  on  the 
thigh  and  not  on  the  ligaments  of  the  knee  joint.  The  spreader 
below  the  foot  should  be  wide  enough  to  prevent  the  straps  from 
pressing  on  the  maleoli.  A  roller  bandage  should  be  applied  over 
the  adhesive  straps  from  the  ankle  to  the  perineum,  and  it  is  well 
to  have  the  turns  of  the  roller  basted  together  or  to  run  a  few  strips 
of  adhesive  lengthwise  of  the  limb,  or  a  coating  of  soluble  glass,  to 
prevent  slipping  of  the  spiral  turns.  The  pulley  fastened  to  the  foot 
of  the  bed  should  be  at  such  a  height  and  at  such  an  angle  that  the 
traction  is  applied,  for  the  time  being,  in  the  direction  of  the  long 
axis  of  the  limb  in  the  attitude  which  it  has  assumed  as  a  result  of 
the  disease.  If  this  position  raises  the  limb  from  the  mattress  it 
must  be  comfortably  blocked  up  with  an  inclined  plane. 

The  weight  should  not  be  hung  upon  the  cord  for  some  hours 
after  the  plaster   straps   are   applied,    so   that   they   have  become 


246  SURGICAL   DISEASES    OF    CHILDREN 

firmly  adherent.  The  rule  often  given  for  approximating-  the  cor- 
rect weight  is  one  pound  for  each  year  of  the  child's  age,  but  this 
ratio  of  weight  increases  too  rapidly.  It  is  scarcely  ever  necessary 
to  use  a  weight  above  three  or  four  pounds  for  a  child  under  ten 
years  of  age.  Too  heavy  a  weight  will  actually  increase  pain*  and  mus- 
cular irritation  and  do  harm  by  stretching  ligamentous  structures. 
Also,  if  the  traction  is  exercised  in  a  direction  other  than  the  proper 
one,  intra-capsular  tension  and  irritation  are  increased.  It  is  often 
advised  that  if  the  weight  tend  to  draw  the  patient  to  the  foot  of  the 
bed  the  foot  of  the  bed  should  be  raised  a  few  inches  from  the  floor 
so  that  the  weight  of  the  patient's  body  acts  as  a  counter-extension. 
This  is  seldom  necessary  when  the  weight  is  not  excessive.  The 
amount  of  weight  should  be  carefully  graduated  to  the  muscular 
strength  and  tension.  It  is  not  intended  by  the  weight  to  at  once 
overpower  the  resistance  of  the  spasmodically  contracted  muscles. 
The  continued  tension  of  a  light  weight  will  ultimately  overcome 
their  contraction;  while  the  relief  afforded  the  inflamed  joint  by 
rest  and  relief  from  irritation  removes  the  reflex  stimulation  which 
caused  the  spasmodic  muscular  action  and  they  relax.  As  they  do 
so  the  inflamed  surfaces  are  more  and  more  separated  and  the  relief 
increases.  It  is  often  surprising  how  soon  the  effect  begins  to  be 
noticeable.  Sometimes  in  a  few  hours  some  relief  is  experienced, 
and  in  a  few  days  the  patient,  who  before  was  fretful  through  the 
day  and  restless,  screaming  at  intervals  at  night,  is  comfortable 
and  happy  all  day  and  sleeping  quietly  at  night.  Appetite  begins  to 
improve  and  fever  to  subside.  In  a  few  days  the  surgeon  will  test 
the  improvement  by  releasing  the  weight  from  the  limb  for  a  few 
minutes  while  he  takes  the  cord  in  his  hand  and  attempts  to  bring 
the  limb  nearer  to  the  axis  of  the  spine.  It  may  be  that  the  position 
can  be  corrected  a  few  inches  both  as  regards  the  flexion  and  the 
adduction  or  abduction  as  the  case  may  be.  But  while  he  lowers  the 
limb  as  soon  as  the  lumbar  spine  begins  to  arch  up  from  the  bed  the 
limit  is  reached  for  the  correction  of  flexion ;  and  while  moving  the 
limb  laterally,  as  soon  as  the  pelvis  begins  to  tilt,  the  movement 
should  be  carried  no  farther,  but  the  pulley  moved  as  necessary  to 
exert  traction  in  the  long  axis  of  the  limb  in  this  improved  position. 
Thus  a  new  adjustment  is  required  once  in  a  few  days,  and  in  a 
week  or  two  the  limb  may  be  quite  horizontal  upon  the  bed  and 
parallel  with'  the  spine. 

It  is  necessary  with  many  children  on  putting  them  to  bed  for 
traction  to  use  means  to  keep  them  quiet  in  the  horizontal  position. 
Some  are  so  unruly  that  it  is  necessary  to  apply  a  long  splint  on  the 
sound  side  from  axilla  to  ankle.  And  often  it  is  necessary  to  pin 
them  down  to  the  mattress.  By  rubber  sheet  and  draw-sheet  under- 
neath them  and  proper  attention,  even  young  and  unruly  children  can 


TUBERCULOSIS   OF  BONES   AND  JOINTS 


Ml 


be  kept  quiet  upon  the  back,  and  no  fear  of  bed-sores.  Bed-sores  in 
a  child  under  any  ordinary  conditions  are  a  disgrace  to  the  nurse. 
After  a  few  days  of  enforced  quiet  the  child  becomes  accustomed  to 
lying  still  and  will  quietly  maintain  the  horizontal  position,  until  he 
improves,  when  he  becomes  playful  and  the  restraining  jacket  or 
chest-band  is  again  required  if  the  recumbent  treatment  is  to  be  pur- 
sued.    About  this  time,  in  a  case  which  is  doing  well,  the  question 


Figs.  83  and  84.     Thomas'  hip  splint, 

must  be  decided  whether  the  patient  is  to  continue  in  bed  or  be  fur- 
nished with  apparatus  for  ambulant  treatment  so  that  he  can  go  out 
of  doors.  Pain  has  been  relieved,  the  muscular  tension  is  gone,  the 
deformity  has  been  overcome,  and  he  has  gained  weight.  It  is  en- 
tirely feasible  to  keep  him  in  bed  for  a  year  or  more  without  detri- 
ment to  his  general  health,  without  bed-sores  or  any  local  mischief 
as  a  consequence,  and  with  the  best  possible  result  to  the  joint. 
But  there  are  means  by  which  treatment  can  be  continued  and  the 
patient  allowed  to  go  about.  These  means  aim  to  employ  traction 
or  fixation  or  both.  One  of  the  best  as  well  as  simplest  of  applications 
and  cheapest  is  the  plaster  of  Paris  splint.  Some  surgeons  apply 
it  as  a  spica  of  the  thigh  and  pelvis.  Some  would  have  us  include 
the  leg  and  thorax.  Usually  it  is  sufficient  to  begin  just  above  the 
knee  and  extend  the  bandage  an  equal  distance  above  the  hip  joint. 


248  SURGICAL  DISEASES    OF   CHILDREN 

This  will  control  motion  in  the  hip.  Some  children  are  so  short 
in  the  pelvis  that  a  splint  which  aims  to  go  no  higher  than  the  pelvic 
crest  and  is  not  too  tight  does  not  control  motion  in  the  hip  joint. 
The  plaster  is  applied  over  either  a  seamless  knitted  garment  or 
a  layer  of  bandage,  and  is  strengthened  with  small  strips  of  wood 
or  a  flat  strip  of  steel  placed  vertically  in  front  of  the  groin.  A  sim- 
ilar piece  bent  to  the  proper  curve  strengthens  the  splint  behind,  but 
can  be  dispensed  with  by  taking  care  to  close  the  opening  apt  to  be 
left  at  the  meeting  of  the  turns  of  the  bandage  on  the  buttock.  The 
sound  foot  is  elevated  by  a  shoe  with  sole  and  heel  from  2^  to  3^ 
inches  thick,  and  the  patient  walks  with  crutches,  carrying  the  foot 
on  the  affected  side  entirely  free  from  the  floor.  Patients  under 
four  years  of  age  cannot  be  trusted  with  crutches.  Boys  take  to 
crutches  a  little  more  readily  than  girls.  Splints  of  leather  or  poro- 
plastic  felt  of  the  same  size  and  shape  as  the  plaster  splint  can  be 
used  with  satisfaction.  The  best  way  to  model  such  a  splint  is  to  cut 
ofif  a  light  plaster  splint,  make  a  cast  by  filling  it  with  plaster,  and 
apply  the  softened  leather  or  felt  to  the  plaster  model,  bandaging 
it  on  until  dry.  Or  leather  may  be  cut  to  shape  from  a  paper  pat- 
tern, soaked  in  cold  water,  applied  to  the  patient  and  allowed  to 
dry  in  position.  Felt  must  be  softened  in  hot  water  and  is  sticky 
and  disagreeable  when  wet.  When  made  over  a  plaster  model  a 
felt  splint  is  very  satisfactory.  Leather  and  felt  splints  are  made 
to  buckle  or  preferably  to  lace  on.  The  Thomas  hip  splint  is  very 
popular  in  England  and  also  much  used  in  this  country.  (See  Figs. 
83  and  84.) 

It  consists  of  a  bar  of  iron  or  steel  shaped  to  fit  the  back  and 
posterior  surface  of  the  limb,  from  just  below  the  scapula  to  the 
lower  third  of  the  leg,  with  a  cross-bar  at  the  top  having  strap  and 
buckle  in  front  around  the  thorax,  one  at  the  lower  end  around 
the  leg,  and  one  at  the  upper  part  of  the  thigh.  Also  supporting 
straps  over  the  shoulders.  I  cannot  agree  with  those  who  consider 
the  Thomas  splint  clumsy  and  ineflicient,  having  often  used  it  with 
great  satisfaction.  It  should  be  shaped  to  fit  the  patient.  A  pattern 
is  made  by  placing  a  strip  of  lead  or  copper  upon  the  patient's  back 
and  limb,  bending  the  metal  to  fit  the  surface,  laying  the  metal  strip 
upon  a  paper  and  tracing  the  outline  with  the  measurements  for 
total  lengths,  and  the  circumference  and  position  of  the  bands.  This 
makes  a  diagram  for  the  instrument  maker  which  should  insure  a 
perfect  fit.  A  bandage  over  the  splint  at  waist  and  thigh  are 
usually  applied.  I  have  sometimes  had  the  splint  made  with  a  pelvic 
belt  of  metal  and  leather  to  go  just  below  the  iliac  crests,  and  an 
extra  thigh  band.  Ridlon's  modification  is  another  form.  (See  Fig. 
85.)  With  a  high-soled  shoe  upon  the  sound  side  and  crutches  the 
patient  goes  about. 

The  plaster,  leather,  felt  and  smiilar  hip  splints,  and  the  Thomas 


TUBERCULOSIS   OF   BONES   AND   JOINTS 


249 


splint  secure  fixation  without  any  attempt  at  traction.    In  some  cases 
as  soon  as  traction  is  removed  the  sensitiveness  about  the  joint  and 
the  muscular  spasm  begin  to  return  and  the  patient 
must  at  once  be  returned  to  bed  with  the  weight 
and    pulley    or    be    provided    with    an    ambulant 
brace  that  applies  traction.    Of  this  type  of  splint 
there  are  several  varieties  and  each  has  modifica- 
tions;  but  a  generally  acceptable  kind  is  Taylor's 
long  hip  splint.     It  consists  of  a  steel  pelvic  band 
to  which  is  attached  a  long  bar  which  extends 
down  the  outer  side  of  the  limb  to  a  point  some 
inches  below  the  foot,  where  it  bends  inward  at 
right  angles  and  has  a  rubber-covered  plate  which 
rests  on  the  floor.     To  the  pelvic  band  are  at- 
tached two  perineal  straps  which  support  the  pa- 
tient when  he  steps  upon  the  splint,  his  foot  not 
reaching  the  ground.     To  the  foot-piece  are  at- 
tached two  straps,  one  for  each  side  of  the  leg. 
These  are  to  be  fastened  into  buckles  which  are 
to  be  attached  by  long  strips  of  adhesive  plaster 
to  the  limb  as  would  be  done  with  Buck's  exten- 
sion.    The  side-bar  is  made  with  a  ratchet  and 
key    by    which    the 
bar   can  be   length- 
ened   or    shortened. 
A     cheaper     splint 
upon  the  same  prin- 
ciple   is    shown    in 
Fig.  86.    To  put  on 
the  splint  or  brace, 
the    patient    should 

lie  upon  his  back  while  the  adhesive 

straps  are  applied,  one  at  each  side  of 

the  limb,    a  buckle  being   strongly  at- 
tached to  each  strap  at  its  lower  end 

just  above  the  maleolus,   and  held  in 

place  by  a  spiral   roller,  the  bandage 

being    held    from    slipping    down    by 

strips  of  adhesive  plaster.    A  shoe  and 

stocking  are  worn,  the  stocking  having 

openings    through    which    the    buckles 

project.    The  pelvic  band  of  the  splint  is 

buckled  in  position,  the  perineal  bands 

are  drawn  just  tight  enough  to  keep 

the  pelvic  band  below  the  iliac  crests 

and  above  the  trochanters.    The  foot  straps  arc  buckled  into  the  side 


Fig.  85. 

Ridlon's 
modification 
OF  Thomas' 

HIP    SPLINT. 

Combines    the 

Thomas   knee   and 

hip    splints. 


Fig.   86.  Hospital 

SPLINT.  Practically 

same      as  Taylor's, 
cheaper. 


LONG 

the 
but 


250  SURGICAL  DISEASES    OF   CHILDREN 

straps  of  adhesive  which  draw  upon  the  Hmb,  and  the  brace  is 
lengthened  until  the  side  straps  making  extension  and  the  perineal 
bands  counter-extension  are  just  sufficiently  taut  to  secure  proper 
traction.  When  this  is  done  the  foot-piece  should  be  several  inches 
below  the  sole  of  the  shoe,  far  enough  to  make  it  impossible  for 


Fig.    87.    Phelps'    hip  crutch    and     Fig. 
fixation   splint. 


RiDLON'S      TRACTION      HIP 
SPLINT. 


the  foot  to  bear  any  weight.  It  may  be  said  of  this  method  of 
traction,  as  of  the  weight  and  pulley,  that  it  is  not  so  much  the 
amount  of  the  traction  as  it  is  its  constancy  that  overcomes  the 
muscular  spasm  and  secures  rest  for  the  joint.  With  a  raised  sole 
on  the  sound  foot  and  a  pair  of  crutches  the  patient  goes  about  com- 
fortably and  safely. 

The  Phelps  hip  splint  is  an  ingenious  and  excellent  apparatus; 
but  is  more  expensive,  harder  to  fit,  and  requires  greater  nicety  of 
adjustment  during  treatment.  It  consists  of  a  pelvic  metal  band 
from  the  outer  side  of  which,  sloping  inward  and  downward,  a  band 


TUBERCULOSIS   OF   BONES   AND   JOINTS  251 

encircles  the  affected  thigh.  From  the  inner  side  of  the  latter  band, 
at  the  perineum,  a  side-bar  descends  to  the  foot-piece  which  extends 
below  the  foot  and  is  attached  to  the  limb,  as  with  the  Taylor  brace. 
But  the  Phelps  brace  has  two  additional  features,  an  upright,  which 
rests  upon  the  pelvic  band  and  extends  upward  to  a  band  encircling 
the  chest  like  a  Thomas  splint,  and  an  arm,  which  extends  downward 
from  the  pelvic  band  on  the  same  side  to  a  thigh  band.  This  arm  is 
so  jointed  to  the  pelvic  band  that  the  thigh  band  encircling  the  upper 
portion  of  the  thigh  can  be  drawn  away  from  the  median  line,  by 
this  lateral  traction  pulling  the  head  of  the  femur  away  from  the 
acetabulum.  (See  Fig.  87.)  There  are  other  splints  designed  to  ac- 
complish the  same  thing  either  by  pulling  or  pushing  laterally  upon 
the  femur.  But  while  they  are  correct  in  principle  they  have  been 
found  not  only  difficult  of  application  but  unnecessary  in  practice. 
Ridlon's  traction  hip  splint  secures  efficient  fixation  and  traction, 
(See  Fig.  88.) 

These  methods  and  means  of  traction  with  ambulant  splints 
constitute  what  is  sometimes  called  "  the  American  plan,"  having 
been  devised  and  perfected  and  advocated  by  such  American  sur- 
geons as  Davis,  Sayre,  Taylor,  Gibney,  Bradford,  and  Shaffer.  When 
a  patient  first  begins  to  wear  a  brace  some  difficulty  may  be  ex- 
perienced in  preventing  chafing  of  the  skin.  But  by  cleanliness  and 
care,  free  use  of  astringent  washes  and  drying  powders  and  frequent 
changing  of  the  temporary  coverings  of  the  perineal  straps,  the  skin 
will  become  tolerant  and  easily  managed. 

The  question  will  arise  as  to  when  the  treatment  may  be  dis- 
continued. No  promise  should  be  made  by  the  surgeon  as  to  a 
definite  time.  As  before  stated,  treatment  will  probably  require  one 
year  and  maybe  two  or  more.  Quite  frequently  a  year  and  a  half 
has  completed  the  cure.  Occasionally  a  patient  is  apparently  well 
in  nine  months.  Owing  to  the  persistent  nature  of  the  disease  and 
the  liability  of  recurrence,  the  apparatus  should  not  be  laid  aside 
until  from  three  to  six  months  after  all  pain,  tenderness  and  mus- 
cular spasm  have  disappeared  from  the  limb.  Then  its  use  should 
only  gradually  be  discontinued  by  leaving  it  off  a  part  of  the  day, 
then  all  day,  then  also  at  night ;  the  high  sole  on  the  sound  side  and 
the  crutches  being  still  retained.  At  any  sign  of  a  return  of  symp- 
toms treatment  must  be  resumed.  If  all  goes  well  the  limb  may 
very  cautiously  and  gradually  be  put  to  use. 

Treatment  of  Abscesses. — Abscesses  and  their  situation  have 
been  described  in  the  general  discussion,  and  their  treatment  alluded 
to  under  the  heading  of  iodoform  injections  and  the  Bier  treat- 
ment. Great  discrepancy  of  opinion  and  practice  as  to  the  treat- 
ment of  abscesses  in  hip-joint  disease  has  prevailed,  some  advocat- 
ing an  entirely  expectant  plan,  hoping  for  the  absorption  and  disap- 


252  SURGICAL   DISEASES    OF   CHILDREN 

pearance,  or  the  quiet  and  harmless  evacuation  which  sometimes  take 
place.  Others  are  for  opening  the  abscess  cavity,  scraping  out  the 
lining  and  either  closing  immediately  or  packing  the  cavity  with 
iodoform  gauze.  There  is  no  good  rule  that  will  apply  to  all  these 
cases.  Some  abscesses  are  small  and  cold,  and  make  little  disturb- 
ance locally  and  none  in  a  general  way.  While  others  are  large 
or  more  active,  and  may  burrow  and  destroy  far  and  wide,  or  pro- 
duce fever,  pain  and  emaciation.  The  first  class  may  well  be  let 
alone.  The  second  class  should  be  dealt  with.  As  to  the  method 
of  opening  and  scraping,  it  would  be  very  good  if  one  could  be 
sure  before  operating  that  every  part  of  the  abscess  cavity  and  its 
sinus,  and  accessory  sinuses  and  their  cavities  could  be  reached  and 
their  tuberculous  infection  thoroughly  eradicated.  But  how  often 
is  this  the  case?  While  any  wound-making,  without  eradication, 
invites  general  tuberculous  infection ;  and  any  opening  risks  the 
addition  of  pyogenic  infection.  When  an  abscess  is  large  or  in- 
creasing or  causing  marked  local  or  general  disturbance  it  is  much 
better  that  it  should  be  evacuated,  with  strict  antiseptic  precautions. 
In  order  that  there  be  as  little  risk  as  possible  of  admission  of 
pyogenic  germs  and  escape  afterwards  of  the  substance  injected, 
this  evacuation  should  take  place  through  a  canula  or  a  very  small 
opening.  An  aspirating  needle  is  generally  too  small;  there  are 
often  curds  and  flakes  of  "  pus  "  and  debris.  The  cavity  should  be 
washed  out  with  3  to  5  per  cent,  boracic  acid  or  i  to  2000  bichloride 
solution,  the  latter  to  be  followed  with  sterile  water.  Then  the  iodo- 
form emulsion  should  be  injected — a  few  drachms  to  an  ounce,  pre- 
pared and  used  as  before  described,  and  sealed  in  with  collodion  or 
a  gauze  pad.  This  procedure  may  have  to  be  repeated  two  or  three 
times  at  intervals  of  ten  days  to  three  weeks  before  the  cavity  will 
cease  to  refill,  and  remain  quiescent. 

Operative  Treatment. — Comparatively  few  of  the  cases  of  hip- 
joint  disease  coming  early  and  receiving  proper  treatment  will  ever 
require  operative  interference.  Those  which  have  been  neglected 
in  the  beginning  and  a  few  in  which  the  system  seems  particularly 
vulnerable  to  the  tubercular  process  and  irresponsive  to  treatment 
may  go  on  until  such  a  stage  is  reached  that  an  operation  is  im- 
perative. No  hard  and  fast  rule  can  be  laid  down.  Each  case  must 
be  judged  upon  its  own  merits.  This  will  require  a  consideration 
of  both  the  local  and  general  condition,  and  the  history  of  the  case 
as  to  what  manner  of  treatment  had  been  used  and  for  how  long; 
whether  the  principle  of  rest  had  been  obeyed  and  had  had  a  fair 
trial,  together  with  the  other  local  and  general  measures  that  often 
produce  remarkable  changes  in  apparently  hopeless  cases  which 
have  not  been  placed  under  favorable  conditions.  If  there  is  ex- 
tensive destruction  about  the  joint,  as  evidenced  by  deformity,  by 


TUBERCULOSIS   OF   BONES   AND   JOINTS  253 

sinuses  leading  down  to  necrosed  bone,  abscess  cavities  still  sup- 
purating, the  local  condition  preventing  any  general  improvement 
or  rendering  it  worse  in  spite  of  proper  treatment,  there  is  no  choice 
but  to  operate. 

Arthrectomy  is  not  very  well  adapted  to  the  hip- joint. 

Excision  is  the  operation  usually  demanded  by  the  condition 
and  the  structure  of  the  joint.  If  excision  were  done  before  the 
peri-articular  structures  were  implicated,  the  results  would  be  far 
better.  It  is  usually  not  resorted  to  until  it  is  evident  that  milder 
means  are  a  failure,  and  by  this  time  the  parts  all  about  the  joint 
are  involved  even  if  they  were  not  at  first. 

The  patient  is  placed  upon  the  sound  side  and  the  operation 
is  done  with  careful  antiseptic  preparation,  including  the  opening, 
draining  and  scraping  of  all  sinuses  and  abscesses  in  the  neighbor- 
hood of  the  joint  or  connected  with  it. 

A  number  of  different  incisions  are  recommended  for  giving 
access  to  the  joint.  The  old  crucial  incision  is  no  longer  used.  The 
curved  incision  of  Oilier  and  the  still  more  convex-posterior  incision 
of  Sayre  give  access  to  the  joint  but  are  longer  than  is  ahvays  neces- 
sary. The  straight  incision  of  Langenbeck  is  made  with  the  thigh 
flexed  to  an  angle  of  45  degrees.  It  begins  above,  in  line  with  the 
posterior  end  of  the  inferior  curved  line  of  the  ilium  and  goes  directly 
down  upon  the  joint,  its  lower  end  being  just  below  the  apex  of  the 
great  trochanter.  It  need  not  be  more  than  two  or  three  inches 
long  and  opens  the  joint  from  its  upper  and  back  part  to  the  tro- 
chanter. It  generally  gives  as  much  room  as  is  necessary.  Perhaps 
it  will  only  be  necessary  to  remove  the  separated  epiphysis.  But  all 
the  diseased  part  of  the  femur  should  be  removed.  Healthy  perios- 
teum should  be  spared  and  no  sound  bone  sacrificed.  The  trochanter 
should  be  spared  if  possible.  If  it  is  necessary  to  remove  the  whole 
femoral  neck  and  trochanter,  all  muscular  attachments  must  be  sepa- 
rated. Then,  if  convenient,  the  thigh  may  be  adducted  and  the  bone 
thrust  out  through  the  incision  to  be  sawn ;  or  a  chain  saw  or  osteo- 
tome can  be  used  in  the  depth  of  the  wound.  Loose  fragments  or 
sequestra  from  the  acetabulum  may  be  removed,  but  it  is  not  advis- 
able to  attempt  to  scoop  or  gouge  away  all  the  soft  bone  within 
reach.  If  the  acetabulum  be  perforated  and  an  abscess  within,  the 
opening  should  be  enlarged  to  afTord  free  exit.  Free  irrigation  with 
hot  bichloride  solution  is  followed  by  a  suture  or  two  at  the  angles 
of  the  wound.  The  cavity  is  packed  with  iodoform  gauze  and  dressed 
with  sterile  or  cyanized  gauze,  cotton  and  adhesive  straps.  Buck's 
extension  is  applied  with  the  weight  very  carefully  graduated,  and 
sandbags  to  steady  the  limb ;  or  a  long  splint  interrupted  at  the  hip 
may  be  used.  The  wound  may  be  dressed  on  the  third  or  fourth  day, 
merely  by  removing  the  gauze  packing  and  introducing  fresh.     A 


254  SURGICAL   DISEASES    OF   CHILDREN 

few  years  ago  Barker  and  other  English  surgeons  attempted  im- 
mediate closure  after  excision  of  the  hip,  and  they  did  succeed  in 
some  cases.  But  it  is  so  difficult  to  remove  every  particle  of  the  dis- 
ease and  leave  the  tissues  sufficiently  sound  for  immediate  union  that 
the  practice  cannot  be  advised  for  general  use.  Usually  there  will 
be  some  suppuration,  and  irrigation  at  each  dressing  with  sterile  salt 
solution  may  be  necessary  before  repacking.  The  wound  closes  by 
granulation.  The  femur  should  not  be  held  by  the  extension  at  too 
great  distance  from  the  acetabulum.  Fibrous  ankylosis  is  the  rule. 
The  patient  may  be  allowed  up  and  around  with  a  Taylor  or  Thomas 
splint  or  a  fenestrated  plaster  splint,  before  the  wound  is  closed. 
Several  months  should  elapse,  however,  after  complete  healing  before 
he  should  be  allowed  to  use  the  limb.  It  will  not  be  strong  for  a 
year  or  more. 

Amputation. — Amputation  for  incurable  hip- joint  disease  in 
children  is  comparatively  rarely  resorted  to  in  this  country  at  the 
present  day.  It  is  very  unusual  to  have  a  case  so  neglected  or  so  in- 
tractable as  to  require  it.  The  indications  for  amputation  as  formu- 
lated by  Marsh  can  hardly  be  improved  upon :  "  When  hip  disease 
is  complicated  with  extensive  disease  of  the  shaft  of  the  femur,  at- 
tended with  copious  and  persistent  suppuration,  and  especially  if 
amyloid  degeneraion  is  making  its  appearance,  when  excision  has 
been  performed  but  has  failed  to  arrest  suppuration,  and  the  general 
health  has  given  way.  When  the  patient,  as  the  result  of  extensive 
disease  of  the  joint,  is  steadily  losing  ground,  and  when  it  is  believed 
that  his  general  health  would  not  enable  him  to  carry  out  repair  after 
excision.  In  some  instances  of  free  suppuration  associated  with  dis- 
ease of  the  pelvis,  amputation  may  be  advantageous  either  by  secur- 
ing free  drainage,  or  by  enabling  the  operator  to  remove  diseased 
bone  that  cannot  otherwise  be  reached.  The  presence,  however,  of 
disease  of  the  pelvis  which  is  either  extensive  or  of  long  standing 
must  generally  be  regarded  as  a  strong  reason  against  the  operation." 
And  yet  the  disease  may  be  only  in  the  neighborhood  of  the  acetabu- 
lum, or,  as  Wright  remarks,  it  may  be  necrosis  and  not  caries,  and 
the  disease  in  the  limb  may  be  preventing  repair  in  the  pelvis.  Under 
these  conditions  pelvic  disease  does  not  contra-indicate  amputation. 

The  operation  is  better  borne  than  might  be  expected.  If  once 
the  effects  of  shock  and  hemorrhage  are  past,  recuperation  is  rapid. 
The  best  method  of  amputation  is  that  of  Furneux  Jordan.  While 
this  is  a  good  method  of  amputation  under  any  condition  not  requir- 
ing remioval  of  the  soft  parts  at  the  inner  side  of  the  thigh,  it  has 
special  advantages  in  children,  in  whom  one  must  be  very  saving  of 
blood ;  and  in  cases  that  have  previously  been  resected.  Inasmuch 
as  this  operation  has  frequently  been  described  differently  from  the 
way  Mr.  Jordan  first  performed  and  described  it,  I  shall  give  here 


TUBERCULOSIS    OF   BONES    AND   JOINTS  255 

a  correct  description  of  the  original  method  ahnost  in  Mr.  Jordan's 
own  words.  The  Hmb  is  exsanguinated  as  completely  as  possible  by 
the  Esmarch  bandage  and  by  position,  and  a  tourniquet  put  over  the 
external  iliac  artery.  A  straight  incision  is  made  on  the  outer  side 
and  the  trochanters  and  upper  part  of  the  shaft  freed  from  their 
muscular  attachments.  The  capsule  is  opened,  the  femur  freed,  enu- 
cleated for  quite  a  distance  down  the  thigh,  the  skin  drawn  upward 
and  the  soft  parts  cut  straight  through.  No  bone  being  left,  the 
muscles  retract  and  are  easily  covered  by  the  skin.  Larger  vessels 
are  tied  with  catgut,  the  wound  between  acetabulum  and  gluteal 
region  packed  to  stop  oozing.  Adjustment  made  by  deep  silver 
sutures.  The  advantages  are  that  the  wound  is  less  severe,  the  cut 
surfaces  less  extensive,  and  further  removed  from  the  trunk ;  ordi- 
narily less  shock,  less  hemorrhage,  less  opportunity  for  septic  infec- 
tion ;  vessels  more  easily  dealt  with.  The  soft  parts  may,  if  the  sur- 
geon prefer,  be  divided  circularly,  after  retracting  the  skin,  but  be- 
fore the  bone  is  enucleated,  through  an  incision  on  its  outer  side. 
The  main  principles  of  the  operation  are  "  enucleate  the  bone  where 
it  is  most  thinly  covered ;  cut  across  the  soft  parts  where  they  are 
smallest ;  do  not  touch  the  bulky  soft  parts  at  the  inner  and  upper 
parts  of  the  thigh."  Wright  advises  ligaturing  the  femoral  or  ex- 
ternal iliac  as  a  preliminary ;  although  he  thinks  "  elevating  the  limb 
before  operation  and  digital  pressure  with  the  help  of  an  elastic 
tourniquet  in  the  early  stages  of  the  operation  are  as  efficient  means 
of  controlling  the  hemorrhage  as  any." 

Double  Hip-joint  Disease  may  occur.  The  onset  is  not  usually 
quite  simultaneous  on  the  two  sides.  Treatment  can  be  carried  out 
for  both  joints  at  the  same  time. 

TUBERCULOSIS  OF  THE  KNEE-JOINT 

Tuberculosis  of  the  Knee-joint — (Tumor  Albus;  White  Swell- 
ing of  the  Knee-joint) — is  one  of  the  common  and  important  affec- 
tions of  the  joints.  Nearly  one-third  of  all  the  joint  diseases  of  chil- 
dren are  tuberculosis  of  the  knee.  According  to  Willemer,  as  quoted 
by  Senn,  in  patients  under  ten  years  of  age  the  starting  point  of  the 
disease  is  in  the  synovial  membrane  in  39  per  cent,  of  the  cases,  and 
in  one  or  both  of  the  articular  extremities  of  the  bones  in  61  per 
cent.  With  patients  between  10  and  20  years  of  age  49  per  cent,  are 
synovial  and  51  per  cent,  osseous;  above  20  years  of  age  23  P^r  cent, 
are  primarily  synovial  and  65  per  cent,  primarily  osseous.  The  knee 
shows  a  larger  percentage  of  cases  of  synovial  origin  than  in  hip 
disease.  The  tubercular  synovitis  of  the  knee  is  generally  one  of  two 
varieties — tubercular  hydrops  or  fungous  synovitis.  Of  these  the  lat- 
ter is  far  more  common,  the  knee-joint  often  presenting  the  typical 
specimens  of  pulpy  degeneration.     It  generally  begins  at  the  folding 


2S6 


SURGICAL  DISEASES  OF   CHILDREN 


of  the  synovial  membrane,  but  finally  involves  the  whole  joint.  The 
para-articular  structures,  including  the  ligaments,  are  affected  early, 
causing  the  large,  dense,  gelantinous  mass  which  appears  at  the  joint. 
This  mass  contains  cheesy  foci  which  break  down  and  form  local 
abscesses.     (See  Tubercular  Arthritis.) 

Suppuration  often  takes  place  also  within  the  joint.  When  the 
disease  begins  in  one  or  both  of  the  bones  of  the  articulation  there 
is  great  alteration  and  destruction.  Deformity  due  to  muscular  con- 
traction is  one  of  the  pathological  changes  resulting  from  tumor 

albus.  (See  Fig.  89.) 
The  approach  of  the  dis- 
ease is  usually  insidious. 
It  may  be  attributed  to 
som.e  injury. 

Symptoms.  —  Lame- 
ness is  an  early  symp- 
tom and  may  appear  be- 
fore pain  and  swelling, 
but  these  follow.  Limp 
is  due  to  muscular  con- 
traction which  causes 
slight  flexion  and  stiff- 
ness, rather  than  tender- 
ness. These  symptoms 
come  on  slowly  but  in- 
crease persistently  until 
all  are  well  marked. 
Pain  is  generally  not 
very  severe.  Muscular  atrophy  appears,  which  makes  the  increasing 
swelling  of  the  joint  more  conspicuous.  The  swelling  is  rounded, 
smooth  and  white,  and  feels  quite  firm.  When  there  is  abscess,  or 
effusion  in  the  joint,  fluctuation  may  be  detected.  Muscular  contrac- 
tion increases,  the  joint  being  flexed.  The  continuous  traction  of  the 
flexors  upon  the  joint  produces  subluxation  of  the  tibia  backward 
upon  the  femur.  The  swelling  in  front  exaggerates  the  appearance 
of  this  condition.  The  leg  is  also  rotated  outward.  This  flexion, 
subluxation  backward,  and  outward  rotation  are  sometimes  grouped 
as  "  the  triple  displacement."  The  knee  becomes  ankylosed  in  this 
position.    The  temperature  of  the  joint  is  perceptibly  elevated. 

Diagnosis. — In  the  early  stage  of  lameness,  pain  and  tenderness 
with  some  swelling,  the  trouble  may,  as  usual,  be  mistaken  for  rheu- 
matism. Osteo-myelitis  and  syphilitic  arthritis  and  sarcoma  must 
be  excluded.  Gonorrheal  arthritis  is  not  impossible  in  children  and 
should  be  excluded.  It  has,  though  rarely,  occurred  when  purulent 
discharge  was  not  perceptible  from  any  mucous  surface    Referred 


Fig.  89.  Tuberculosis  of  knee-joint. 
"  White  swelling,"  muscular  contraction, 
and  subluxation.  ^  Treated  by  fixation 
and  gradual  extension.  Boy  aged  5  years. 


TUBERCULOSIS    OF   BONES    AND   JOINTS  257 

pain  from  hip  or  sacro-iliac,  or  spinal  disease  should  be  borne  in 
mind.  The  slow  advancement  and  muscular  atrophy  are  character- 
istic. Muscular  rigidity  is  the  most  common  and  reliable  symptom ; . 
with  limitation  of  motion,  most  noticeable  at  the  extremes  of  the 
normal  range.  Gentle  passive  motion  will  usually  elicit  the  spas- 
modic muscular  contraction  even  before  rigidity  is  marked. 

Prognosis. — This  disease  is  very  chronic  in  its  course  and  will 
continue  from  a  year  to  two  or  three  or  more  years.  Treatment  will 
shorten  the  course  of  the  disease  and  greatly  modify  the  outcome,  but 
will  never  abort  it. 

If  the  disease  is  not  treated  it  will  go  on  to  destruction  of  the 
joint,  and,  at  the  best,  result  in  ankylosis  in  a  position  of  deformity, 
if  the  patient  is  not  carried  off  too  soon  by  general  tuberculosis  or 
pulmonary  tubercular  meningitis  or  amyloid  disease.  With  treat- 
ment the  result  will  depend  largely  on  when  the  treatment  is  begun, 
as  well  as  upon  its  location  and  the  general  condition  of  the  patient. 
Under  somewhat  favorable  conditions  and  treated  from  the  besfin- 
ning,  recovery  may  result  with  very  little  impairment.  At  least  ab- 
scesses and  ankylosis  may  be  prevented.  If  treatment  is  not  begun 
until  there  is  great  swelling,  flexion  and  formation  of  abscess,  the 
best  that  will  probably  be  accomplished  will  be  a  control  of  the  inflam- 
mation without  farther  involvement,  and  a  result  with  ankylosis  in 
a  useful  position.  An  advanced  case,  with  destruction  in  articular 
bones  requiring  resection,  can  at  the  best  result  in  nothing  better 
than  bony  ankylosis  with  shortening. 

Treatment. — The  constitutional  treatment  has  been  discussed 
under  Tuberculosis  and  Tubercular  Arthritis.  The  local  treatment 
consists  in  rest,  counter-irritation  and  compression,  the  evacuation 
and  injection  of  abscesses,  tapping  and  injection  or  incision  and 
drainage  of  the  joint,  peri-articular  injections,  correction  of  deform- 
ity, erasion  and  resection. 

The  most  important  therapeutic  factor  is  rest.  This  may  be 
secured  by  various  methods,  and  that  method  should  be  chosen 
adapted  to  the  stage  of  the  disease  and  condition  of  the  case.  If 
seen  early  and  there  is  no  acute  pain  or  tenderness,  fixation  by  a 
plaster  bandage  from  the  ankle  to  the  perineum,  with  a  high  sole 
(three  inches)  on  the  sound  foot,  and  a  pair  of  crutches,  meet  the 
indications.  If  there  is  quite  severe  pain  and  some  tenderness  about 
the  joint,  a  good-sized  patch  should  be  touched  with  the  Paquelin 
cautery  before  the  plaster  is  applied.  If  the  knee  is  very  painful, 
tender,  considerably  swollen,  and  there  is  marked  spasm  of  the  mus- 
cles with  flexion,  nothing  will  relieve  all  the  symptoms  so  promptly 
as  bed,  and  traction  with  weight  and  pulley.  The  traction  should, 
of  course,  be  made  in  the  long  axis  of  the  leg,  which  will  gradually 
approach  the  long  axis  of  the  thigh  as  improvement  occurs.    In  the 


25S 


SURGICAL   DISEASES    OF   CHILDREN 


course  of  a  few  weeks  this  treatment  will  usually  prepare  the  limb 
for  some  form  of  ambulant  apparatus,  such  as  the  plaster  bandage  or 
the  Thomas  knee-splint.  This  splint  consists  of  two  steel  uprights 
connected  at  the  top  with  a  ring  which  encircles  the  thigh  at  the 
perineum,  and  at  the  bottom  with  a  crossbar  a  few  inches  below  the 
foot.  The  thigh  and  leg  have  each  a  trough-like  case  in  which  the 
back  of  the  limb  rests,  being  held  in  its  place  b}^  straps  or  bandages 


Fig.  go.  Same  case  as  Fig.  89  after 
reduction  of  the  deformity  by  ex- 
tension, and  Thomas'  knee  splint 
applied. 


Fig.  91.  Same  case  as  Figs.  89  and 
90  cured,  with  10  degrees  of  mo- 
tion in  the  knee. 


around  splint  and  limb.  (See  Figs.  90  and  91.)  The  ring  at  the 
top  is  padded,  and  when  the  patient  steps  upon  the  splint  his  weight 
is  borne  upon  the  tuber  ischium.  The  sound  foot  is  supplied  with  a 
high-soled  shoe.  Thus  the  limb  is  immovably  fixed,  while  weight- 
bearing  is  prevented  though  the  patient  goes  about.  If  there  is 
flexion  without  real  subluxation,  it  may  be  overcome  by  a  gradual 
straightening  process,  by  adjustment  of  the  bands,  or  even  by  a  bend 
in  the  uprights  of  the  Thomas  splint.  Where  there  is  alteration  of 
the  articulating  bones  and  shortening  of  the  posterior  ligaments,  as 
frequently  results  from  flexion  and  contraction  of  muscles,  simple 


TUBERCULOSIS   OF   BONES   AND   JOINTS 


259 


straightening  does  not  reduce  the  subluxation.  If  it  is  desired  to 
use  traction  in  connection  with  the  Thomas  splint,  it  is  very  easily 
managed  by  applying  side  straps  of  adhesive  plaster  to  the  leg  and 
attaching  them  to  straps  upon  the  crossbar  at  the  bottom,  as  was  de- 
scribed in  traction  with  the  Taylor  splint  for  hip  disease.  When 
using  plaster  for  fixation  in  a  case  with  deformity  by  flexion,  the 
knee  is  placed  in  as  correct  a  position  as  is  comfortable,  no  force 
being  used,  before  the  plaster  is  applied  ;  and  when,  in  a  week  or  two, 
the  plaster  bandage  is  renewed,  it  will  be  found  that  the  joint  can 
be  still  further  improved  in  position,  until  finally  the  deformity  will 
be  entirely  corrected.  The  same  thing  can  be  accomplished  with  a 
splint  hinged  at  the  knee,  with  fly-nuts  at  the  joints,  so  that  ex- 


FiG.  92.     Splint  for  gradual  extension  of  knee  or  elbow. 

tension  can  be  gradually  brought  about  by  a  slight  change  at  inter- 
vals of  a  few  days,  the  limb  being  continuously  quite  immobilized 
by  the  splint.  (See  Fig.  92.)  This  appliance  leaves  the  knee  ac- 
cessible for  inspection  or  dressing  in  case  of  abscess  or  a  discharg- 
ing sinus. 

Thus  the  measures  employed  for  fixation  usually  also  correct 
the  deformity.  It  is  not  advisable  to  attempt  to  correct  deformity  by 
leverage  upon  the  joint,  and  immediate  correction  by  force  is  a  dan- 
gerous procedure  when  there  is  any  active  tubercular  disease  present. 
If  the  disease  has  subsided,  but  the  joint  is  left  badly  flexed  with  tibia 
subluxed  backward,  traction  can  efifect  little  toward  improvement. 
However,  it  should  be  given  a  trial,  as  some  cases  yield  unexpectedly. 
A  careful  attempt  may  be  made  under  anesthesia  to  break  the  ad- 
hesions ;  and  in  some  cases  the  contracted  hamstring  tendons  may  be 
divided.  But  in  cases  where  there  has  been  much  inflammation  in 
the  popliteal  space  attempts  at  forcible  straightening  may  result  in 
injury  to  the  vessels.  To  effect  reduction  of  these  obstinate  anky- 
losed  dislocations  a  number  of  mechanical  appliances  have  been  in- 
vented, such  as  Goldthwait's  genuclast  and  Peters'  wrench.     They 


26o  SURGICAL   DISEASES    OF   CHILDREN 

are  powerful  levers  which  make  a  fulcrum  of  the  lower  end  of  the 
femur  anteriorly  and  apply  the  pressure  close  below  the  head  of  the 
tibia  posteriorly.  Ordinarily  manual  force  furnishes  all  the  power 
compatible  with  safety  in  work  upon  young  children.  If  all  attempts 
at  straightening  fail,  resection  or  osteotomy  by  removing  a  wedge 
from  the  lower  third  of  the  femur  may  he  resorted  to. 

The  teatment  of  abscesses  has  been  sufficiently  discussed  else- 
where. 

When  pain  and  muscular  spasm  and  tenderness  have  been 
absent  for  a  period  of  three  to  six  months  the  patient  may  be  allowed 
to  use  the  limb  for  weight-bearing,  at  the  same  time  protecting  the 
joint  by  a  splint.  The  splint  may  be  removed  daily  and  motion  tried. 
If  moderate  walking  and  passive  motion  cause  no  return  of  symptoms 
after  a  few  weeks  the  splint  or  brace  may  be  laid  aside  entirely.  If, 
however,  there  is  any  return  of  pain  or  muscular  rigidity,  the  fixation 
apparatus  should  be  resumed.  Some  surgeons  consider  weight-bear- 
ing admissible  early  in  the  treatment — as  soon  as  the  active  symptoms 
have  been  quieted — claiming  that  it  does  no  harm  if  fixation  be  main- 
tained. This  may  be  true  in  some  cases.  Yet  in  the  majority  of 
cases  and  in  hands  not  extremely  familiar  with  all  the  phases  of  the 
disease,  it  is  safer  to  interdict  both  weight-bearing  and  motion  until 
the  case  is  cured.  A  degree  of  enlargement  will  remain  about  the 
joint  after  all  pain,  spasm  and  tenderness  have  disappeared,  in  fact, 
even  after  it  is  cured. 

Arthrotomy. — But  the  joint  will  not  always  pursue  the  favorable 
course  here  described.  Even  after  the  most  appropriate  and  faith- 
ful treatment,  including  skillful  conservative  management  of  ab- 
scesses outside  of  or  within  the  joint,  with  evacuations  or  injections, 
suppuration  within  the  joint  may  continue,  with  proliferation  and 
degeneration  of  the  fungous  growth.  In  such  a  case,  if  the  general 
health  of  the  patient  remains  sufficiently  good  or  at  least  does  not 
demand  immediate  radical  interference,  it  may  suffice  to  open  the 
joint  and  establish  drainage  at  its  lowest  point  and  posteriorly. 

Erosion;  (Arthrectomy,  Synovectomy.) — If  arthrotomy  has 
been  tried  and  has  not  changed  the  behavior  of  the  joint,  or  if  the 
general  health  of  the  child  is  failing  or  amyloid  disease  appearing 
under  prolonged  suppuration,  or  if,  without  suppuration,  the  pulpy 
swelling  increases,  the  best  procedure  to  resort  to  is  erasion.  This 
operation  was  devised  and  executed  and  introduced  by  Wright  of 
Manchester  in  1881.  Grieg  Smith  had  previously  performed  erasion 
on  an  elbow,  although  his  case  was  unknown  to  A\'right,  as  it  was 
not  published  at  that  time.  Volkmann  appreciated  this  operation 
highly  and  published,  in  1885,  a  paper  on  "  Arthrectomia  Syno- 
valis,"  as  he  called  it.  It  was  Oilier  who  described  it  as  synovec- 
tomy.    The  operation  is  designed  to  substitute  resection  in  cases 


TUBERCULOSIS   OF   BONES   AND   JOINTS  261 

where  only  the  synovial  membranes  are  diseased,  while  the  articular 
surfaces  are  intact  or  only  partially  involved,  so  that  diseased  points 
can  be  removed  without  removing  the  whole  articular  extremity.  If 
erasion  succeeds,  the  joint  is  as  sound  as  after  an  excision  but  with- 
out shortening,  either  as  an  immediate  result  of  the  removal  of  the 
articular  ends  of  the  bones,  or  of  accidental  interference  with  the  line 
of  growth.  The  operation  is  appropriately  described  nearly  in  Mr. 
Wright's  own  words.  The  limb  is  Esmarched.  The  knee  is  opened 
freely  by  a  semilunar  incision  as  for  an  excision.  The  skin  is  re- 
flected and  the  capsule  removed  on  each  side  of  the  patella  and 
patellar  ligament,  or,  better,  the  patella  is  sawn  across  and  the  frag- 
ments turned  upward  and  downward.  If  necessary,  free  vertical  in- 
cisions must  be  made  to  reach  as  high  as  the  upper  limit  of  the 
synovial  pouches.  Next  every  particle  of  pulpy  granulation  tissue  is 
carefully  cut  away  with  scalpel  or  scissors ;  all.  the  infiltrated  capsule 
and  the  semilunar  cartilages  are  removed,  and  the  articular  cartilage 
scraped  quite  clean,  any  granulation,  tissue  being  carefully  picked 
out  from  pits  in  the  cartilage,  and,  if  necessary,  any  foci  of  disease 
in  the  bone  gouged  away.  This  process  must  be  most  thorough,  and 
extreme  flexion  of  the  limb  is  required  to  fully  expose  and  clean  the 
back  part  of  the  joint.  The  crucial  ligaments  are  scraped,  but  if 
sound  preserved.  The  lateral  ligaments  are  divided.  The  upper 
synovial  sac  must  be  thoroughly  cleaned.  The  most  difficult  part  of 
the  operation  is  getting  away  the  posterior  part  of  the  semilunar 
cartilages  and  the  synovial  membrane  at  the  back  of  the  joint. 
After  thoroughly  removing  all  pulpy  tissue  it  is  a  good  plan  to  appl}' 
the  actual  cautery  to  any  doubtful  spots.  Any  fistulae  should  be  well 
cleared  out.  The  process  is  tedious,  requiring  an  hour  and  a  half  to 
two  hours,  including  the  subsequent  putting"  up  in  a  splint.  As  soon 
as  all  bleeding  has  been  stopped,  the  limb  is  fixed  on  an  excision 
splint  and  dressed  antiseptically.  Drainage  should  be  at  the  back 
of  the  joint  on  each  side  as  after  excision,  the  tubes  being  carried 
through  openings  made  behind  the  joint.  More  recently  Wright 
used  no  drainage  and  closed  the  wound  entirely.  Usually  healing 
throughout  by  primary  union  is  obtained.  Mobility  after  erasion  is 
a  possibility,  but  should  not  be  attempted  unless  the  interference  with 
the  articular  surfaces  was  not  extensive.  If  ankylosis  without  short- 
ening can  be  obtained  the  outcome  is  gratifying. 

Volkmann  uses  the  Esmarch  constrictor  only  in  exceptional  cases. 
If  the  bursa  beneath  the  quadriceps  is  diseased  he  prolongs  the  in- 
cision to  reach  it  and  removes  it  entire.  This  exposes  the  femur  sev- 
eral inches  above  the  articular  surface.  All  disease  tissue  is  removed 
until  healthy  bone  and  muscular  tissue  are  reached. 

Excision.  Resection. — If  a  case  is  too  bad  for  erasion  or  that 
operation  has  been  tried  and  failed,  or  if  there  is  extensive  deformity 


262  SURGICAL  DISEASES    OF   CHILDREN 

of  the  joint,  rendering  it  useless,  there  still  remains  a  method  of 
eradicating  the  disease  and  restoring  or  partly  restoring  function  by 
excision.  Typical  excision  is  always  to  be  avoided  in  children  if  an 
arthrectomy  or  an  atypical  resection  can  be  safely  substituted,  be- 
cause of  the  danger  of  interference  with  growth  of  the  bone  in 
length,  as  well  as  on  account  of  shortening,  as  was  first  emphasized 
by  Syme.  Yet  when  the  operation  is  unavoidable  the  results  are  bet- 
ter in  children  than  in  adults. 

Concerning  the  questions  of  the  effect  upon  the  growth  of  bone, 
the  reproduction  of  the  articulation  after  resection,  and  the  amount 
of  shortening,  there  has  been  a  great  deal  of  discussion.  Whatever 
may  result  in  the  exceptional  case,  in  the  majority  of  cases  the  dictum 
of  Senn  upon  this  point  will  be  found  excellent  advice :  "  In  chil- 
dren atypical  resection  should  be  practiced  in  all  cases  where  all  the 
foci  in  the  articular  extremities  can  be  reached  and  removed  by  this 
method." 

After  the  joint  has  been  freely  opened  and  all  diseased  soft  parts 
cleared  away,  the  bone  surfaces  are  inspected  for  both  superficial 
and  deep-seated  foci  of  disease  or  of  infection.  Usually  several,  and 
sometimes  many,  foci  will  be  found.  All  cavities  are  exposed  and 
all  diseased  or  suspicious  spots  are  removed  with  sharp  spoon,  chisel, 
gouge,  or  bone  forceps.  If  the  diseased  parts  are  so  situated  as  not 
to  demand  removal  of  the  entire  articular  surface,  a  complete  resec- 
tion need  not  be  made ;  but  a  portion  of  both  bones  can  be  sawn  or 
sliced  out  in  a  shape  to  match  or  splice  together.  This  will  give 
less  shortening  and  a  firmer  union  than  if  both  are  divided  clear 
across.  If  there  are  not  sound  portions  of  bone  to  spare  in  this  or 
a  similar  manner,  typical  resection  must  be  made  by  cutting  both 
bones  across. 

Whether  the  typical  or  atypical  operation  is  made,  the  tibia  is  sawn 
or  sliced  at  such  a  deviation  from  the  right  angle  to  the  long  axis  of 
the  shaft  as  will  place  the  limb  in  a  slightly  flexed  position,  as  if  in 
the  act  of  walking,  when  it  is  brought  in  apposition  with  the  squarely 
cut  end  of  the  femur.  Splicing  is  neither  so  easily  managed  nor  so 
necessary  in  young  children  as  in  older  children  or  adults.  In  cut- 
ting off  the  ends  of  the  bones  it  is  not  intended  to  go  far  enough  back 
from  the  articulating  surface  to  reach  the  bottom  of  every  cavity. 
Only  a  thin  slice  is  removed  and  the  gouge  used  afterward  on  any 
diseased  spot  or  cavity.  The  cross  sections  should  not  approach  the 
epiphyseal  lines.  Wiring  or  pegging  or  nailing  tibia  and  femur  to- 
gether is  not  necessary  in  children,  but  the  patella  which  had  been 
divided  should  be  sutured  with  wire  or  chromicized  catgut.  Drain- 
age should  be  provided  for  by  two  openings  into  the  popliteal  space. 
After  all  oozing  is  stopped  and  the  wound  thoroughly  cleansed  and 
dried,  the  incision  is  entirely  closed,  powdered  with  iodoform  and 


TUBERCULOSIS   OF   BONES   AND   JOINTS  263 

boric  acid  or  camphophenique,  dressed  with  iodoform  gauze,  bichlo- 
ride, or  sterile  gauze  and  bandage  and  put  up  with  a  long  splint  inter- 
rupted at  the  knee.  After  a  few  dressings  the  limb  should  be  put 
into  plaster  of  Paris,  fenestrated  if  there  remains  a  sinus.  Bony 
union  should  take  place  in  one  to  two  months,  but  a  stiff  splint  should 
be  worn  for  two  to  four  years  or  the  union  will  yield,  causing  great 
deformity. 

TUBERCULOSIS   OF  THE  ANKLE 

This  does  not  occur  as  commonly  as  one  would  expect  from  the 
hard  usage  to  which  this  joint  is  subjected,  its  exposed  situation  and 
liability  to  trauma.  Yet  not  very  rarely  it  becomes  the  seat  of  tuber- 
cular processes  similar  to  those  which  have  been  described  in  the 
knee.  Named  in  the  order  of  frequency  the  primary  focus  may  be 
said  to  be  situated  in  the  astragalus,  tibia,  os  calcis,  or  synovial  mem- 
brane; although  statistics  differ  on  this  point.  The  etiology  is  the 
same  as  that  given  for  the  hip  and  knee-joints. 

Symptoms. — The  symptoms  are  lameness,  swelling,  muscular 
spasm,  wasting  of  the  muscles  of  the  leg,  heat,  pain,  and  tenderness. 
Usually  limping  will  be  noticed  first.  The  child  avoids  flexing  the 
foot,  but  rotates  it  outward  in  stepping  forward.  The  limp  is  due 
partly  to  this  and  partly,  but  less,  to  avoiding  weight-bearing.  Swell- 
ing is  an  early  symptom,  especially  if  the  disease  is  synovial  from 
the  beginning.  It  is  most  noticeable  anteriorly  at  first,  then  poste- 
riorly at  each  side  of  the  tendo  Achillis.  Muscular  spasm  is  not  long 
in  making  its  appearance,  though  it  may  not  be  easy  to  demonstrate 
early  in  the  case  unless  the  examination  is  made  with  great  care. 
Later  on,  as  is  also  the  case  with  other  joints,  the  flexors  contract 
strongly.  This  produces  deformity,  the  foot  taking  the  position  of 
equinus. 

Muscular  spasm  does  not  long  continue  before  wasting  of  the 
calf  muscles  is  apparent.  Careful  measurement  with  a  tape,  com- 
paring the  two  limbs  in  the  same  position,  will  detect  it  early,  and 
flabbiness  corroborates  the  finding.  Pain  is  not  near  so  marked  a 
symptoms  as  in  hip- joint  disease.  It  is  unusual  to  have  severe  pain 
or  night-screaming,  though  these  are  not  unknown.  Tenderness  to 
general  pressure  is  not  marked,  the  child  may  not  complain  on  bear- 
ing the  weight  of  the  body,  but  certain  tender  points  can  often  be 
located.  Local  heat  is  an  uncertain  symptom  which  may  or  may  not 
be  present. 

Diagnosis. — The  diagnosis  is  made  upon  the  muscular  spasm, 
wasting  of  the  calf  muscles,  swelling  without  discoloration,  the  con- 
tinued low-grade  heat,  and  the  tenderness.  It  is  differentiated  from 
disease  of  tibia  or  tarsus  by  locating  the  tender  point,  and  by  absence 
of  early  swelling  in  the  joint  itself.  From  teno-synovitis  by  locating 
the  course  of  the  tendons,  and  by  the  crepitus  and  friction  sound  in 


264  SURGICAL   DISEASES    OF   CHILDREN 

the  latter  disease.  In  sprain  there  is  a  history  of  traumatism ;  and  if 
there  is  swelling  it  is  apt  to  be  discolored.  Sprain  and  its  swelling 
are  generally  only  on  one  side  of  the  joint. 

Prognosis. — If  treated  early  the  prognosis  is  very  good.  If  the 
disease  has  progressed  so  far  that  operative  measures  are  necessary 
it  is  unpromising.  Treatment  of  cases  seen  early  will  require  from 
six  months  to  a  year  or  more. 

Treatment. — The  treatment  is  rest.  This  is  secured  in  young 
children  by  keeping  them  lying  in  bed,  with  fixation  of  the  joint 
by  means  of  a  plaster  bandage  or  leather  or  felt  splint.  Older  chil- 
dren may,  after  the  acute  symptoms  have  abated,  be  fitted  with  a 
Thomas  splint  in  addition  to  the  plaster  bandage,  a  pair  of  crutches, 
and  a  high  sole  on  the  sound  foot,  and  allowed  to  go  about.  A 
plaster  bandage  to  immobilize  the  ankle  should  extend  well  up  the 
calf  and  down  to  the  toes,  and  have  no  padding  beneath  it.  The  foot 
should  be  placed  as  near  at  right  angles  with  the  leg  as  the  contrac- 
tion will  allow  before  each  application  of  the  plaster  bandage.  If 
these  means  fail,  and  suppuration  occurs  in  the  joint,  arthrotomy, 
erasion,  or  resection  must  be  resorted  to  as  described  for  the  knee- 
joint,  though  the  prospects  of  recovery  are  not  so  good  as  in  the 
knee. 

TARSAL  TUBERCULOSIS 

Tarsal  tuberculosis  is  usually  synovial  in  its  origin  unless 
located  in  the  os  calcis.  It  should  be  treated  by  rest  and  fixation,  as 
with  disease  of  the  ankle  joint.  If  this  fails,  there  is  a  choice  of 
amputation  or  an  attempt  to  remove  the  diseased  parts  only.  If  any 
operative  interference  whatever  is  attempted  it  should  be  very 
thorough.  Scraping  and  gouging  are  usually  unsuccessful  and  are 
certainly  dangerous.  If  the  disease  is  definitely  located,  and  espe- 
cially if  there  be  sequestra  in  one  or  more  of  the  tarsal  bones,  these 
bones  should  be  removed.  But  the  use  of  probes  in  attempting  to 
locate  or  to  define  the  limits  of  tarsal  disease  is  very  uncertain  and 
unsatisfactory. 

If  synovitis  and  caries  are  general  among  the  bones  of  the  tarsus 
it  is  best  to  remove  them  all.  Wright  considers  this  better  than  either 
a  Pirogoff's  or  Syme's  amputation.  A  transverse  incision  is  made 
on  the  dorsum  and  a  flap  turned  upward,  the  bones  removed,  the 
tendons  reunited;  hemorrhage  controlled,  and  flap  sutured.  After 
dressing,  the  foot  is  put  upon  a  back  splint  with  foot-piece.  This  is 
changed  later  to  plaster  bandage  or  other  portable  fixation  splint. 

TUBERCULOSIS  OF  THE  ELBOW 

Tuberculosis  of  the  elbow  is  common  in  children  between  the 


TUBERCULOSIS   OF   BONES   AND   JOINTS  265 

ages  of  two  and  five  years  or  more.  It  is  primarily  a  synovitis  or 
an  osteitis  in  about  an  equal  number  of  cases.  Sometimes  it  seems 
to  start  in  the  olecranon  bursa,  and  presents  the  usual  symptoms  of 
tubercular  joint  disease,  excepting  pain.  Stiffness,  muscular  tension, 
and  wasting  of  the  muscles,  swelling,  and  sometimes  heat,  are  pres- 
ent. While  there  may  be  pain,  it  is  often  absent,  and  tenderness  is 
not  marked.  In  some  cases  there  is  very  little  increase  of  local  heat. 
The  swelling  in  a  typical  case  is  fusiform,  and  the  joint  is  held  about 
two-thirds  extended.    The  stiffness  may  be  the  first  symptom  of  all. 

If  seen  early,  the  joint  (including  the  arm  and  forearm)  should 
be  brought  as  near  as  possible  to  a  right  angle  with  the  forearm, 
half  way  between  pronation  and  supination,  and  fixed  in  a  splint  of 
plaster,  felt,  leather,  wire,  or  other  material,  and  supported  in  a 
sling.  Treatment  will  require  from  four  months  to  a  year.  If 
abscesses  be  present,  they  must  be  evacuated,  and  the  splint  inter- 
rupted or  fenestrated  so  as  to  allow  for  dressing,  while  fixation  is 
continued.  If  the  bones  have  become  carious  or  pulpy,  the  synovial 
membrane  destroyed,  and  the  soft  parts  riddled  with  sinuses,  ex- 
cision may  have  to  be  done.  If  the  case  is  not  too  bad,  erasion  or  an 
atypical  excision  should  first  be  tried  before  excision  is  resorted  to. 

The  elbow  joint  is  best  exposed  by  the  long  straight  posterior 
incision  of  Langenbeck.  It  passes  just  inside  the  tip  of  the  ole- 
cranon. All  the  soft  parts  are  then  separated  from  the  internal  con- 
dyle. The  ulnar  nerve  should  be  carefully  guarded.  The  anconeus 
should  not  be  cut  across  but  loosened  from  the  olecranon  and  turned 
aside.  Instead  of  severing  the  tendon  of  the  triceps,  the  olecranon 
may  be  cut  across,  which  gives  easy  access  to  the  joint.  If  the 
olecranon  is  subsequently  removed,  the  tendon  should  be  attached  to 
the  ulna,  but  if  removal  of  the  olecranon  is  not  necessary,  when  the 
work  upon  the  joint  is  completed  by  removal  of  all  diseased  tissues, 
the  olecranon  can  be  wired  or  nailed  in  place.  After  hemostasis  and 
dressings,  the  extremity  is  put  up  with  a  right-angled  splint,  with 
the  forearm  half  supinated.  The  first  dressing  is  made  in  a  month,  if 
all  goes  well.  Some  advise  passive  motion  after  two  weeks,  but 
nothing  is  to  be  gained  by  attempting  passive  motion  until  healing 
is  complete.  If  ankylosis  results,  the  extremity  is  in  the  most  useful 
possible  position.  Oftentimes  motion  and  a  surprising  degree  of 
strength  are  obtained. 

TUBERCULOSIS  OF  THE  SHOULDER 

This  joint  is  a  rare  location  for  tuberculosis  in  children.  The 
disease  in  the  shoulder  presents  the  usual  characteristics  of  tubercu- 
lar arthritis,  and  should  be  treated  on  the  principles  already  laid 
down. 


266  SURGICAL  DISEASES    OF   CHILDREN 

WRIST-JOINT  TUBERCULOSIS 

When  the  disease  attacks  the  wrist  there  is  an  additional  feature 
in  the  presence  of  extensive  synovial  sheaths.  Of  the  bones  the 
radius  is  most  frequently  affected,  and  after  that  the  proximal  ends 
of  the  metacarpals. 

The  symptoms  are  those  usual  in  all  tubercular  joint  affections, 
with  a  rather  unusual  amount  of  tenderness  and  pain  on  motion. 
The  most  of  the  swelling  is  on  the  dorsal  surface. 

Diagnosis  is  not  difficult  if  one  exclude  teno-synovitis,  in  which 
the  swelling  is  shallower,  and  the  trouble  not  so  chronic  and  per- 
sistent. 

If  seen  and  treated  early,  the  probability  is  that  a  cure  will  result 
in  four  or  six  months.  Most  cases  do  remarkably  well  with  the 
rest  treatment.  After  suppuration,  caries,  and  sinuses,  the  outcome 
is  uncertain. 

Treatment  consists  in  rest  secured  by  a  plaster  bandage  extend- 
ing from  the  metacarpo-phalangeal  joints  to  the  bend  of  the  elbow, 
allowing  free  motion  of  the  phalanges.  The  arm  is  carried  in  a  sling 
with  the  forearm  halfway  between  pronation  and  supination.  It  is 
very  unusual  to  have  tuberculosis  of  the  wrist  progress  seriously  if 
the  rest  treatment  is  instituted  before  the  disease  is  already  far  ad- 
vanced. If  it  does  not  yield  to  conservative  methods  but  extends, 
forms  abscess,  cavities,  sequestra,  it  must  be  dealt  with  in  an  opera- 
tive way,  removing  all  the  diseased  tissues.  Mere  scraping  or  partial 
removal  will  be  useless  or  worse  than  useless. 

SACRO-ILIAC   DISEASE 

A  disease  very  rare  in  childhood,  but  when  it  does  occur  it  is 
a  very  serious  condition.  It  may  involve  the  synovial  membrane  first, 
but  is  thought  to  originate  more  frequently  in  the  ilium  and  extend 
into  the  joint.  In  some  cases  it  may  be  rather  acute  for  a  tuber- 
culous bone  or  joint  disease,  running  quickly  to  suppuration  and 
hectic,  but  generally  is  quite  chronic.  If  the  patient  does  not  die 
of  exhaustion,  some  other  form  of  tuberculosis  or  an  inter-current 
malady,  the  sacro-iliac  disease  may  go  on  to  destruction  of  synovial 
membranes,  ligaments,  and  bones. 

Symptoms  and  Diagnosis. — The  list  of  symptoms  of  sacro-iliac 
disease  repeats  exactly  that  of  hip- joint  disease,  with  the  exception 
that  muscular  rigidity  is  omitted,  namely,  lameness,  pain,  muscular 
wasting,  swelling,  altered  position  of  the  limb,  tenderness.  The  limp 
lacks  any  characteristic  that  would  give  it  differential  diagnostic 
value.  Pain  is  often  severe,  or  at  least  a  prominent  symptom.  Pain 
may  be  felt  near  the  joint  or  extending  down  the  back  of  the  thigh 
or  in  the  groin  or  front  of  the  thigh,  or  about  the  knee  or  in  the 


TUBERCULOSIS   OF   BONES   AND   JOINTS  267 

fectum  or  bladder.  It  may  be  dull  or  aching.  Pain  is  caused  by 
pressing  together  the  sides  of  the  pelvis  or  by  pressing  them  apart. 
There  is  wasting,  slight  or  greater,  of  the  muscles  on  the  affected 
side,  of  the  gluteal  region  and  the  limb.  Swelling  is  not  always  very 
perceptible,  excepting  in  a  lean  patient,  or  in  an  advanced  case,  or  in 
the  presence  of  abscess,  when  fluctuation  also  may  be  detected. 
Abscess  from  spinal  disease  may  appear  in  this  locality.  The  swell- 
ing or  the  abscess  may  be  located  on  the  inside  of  the  pelvis.  There 
is  either  no  alteration  of  the  position  of  the  limb,  or  else  apparent 
lengthening,  from  tilting  of  the  pelvis,  with  marked  eversion.  The 
limb  is  fully  extended.  In  standing  the  patient  rests  his  weight 
mostly  on  the  sound  limb.    Tenderness  on  pressure  in  the  sacro-iliac 


Fig.    93.     Tuberculous   dactylitis. 

region  is  usually  present  and  aids  in  locating  the  trouble.  Although 
the  symptoms  are  apt  to  mislead,  a  diagnosis  can  be  made  from  the 
pain  produced  by  pressing  the  pelvic  bones  together  or  apart,  the 
absence  of  any  pain  or  limitation  of  motion  about  the  hip-joint  and 
the  absence  of  any  rigidity  or  angular  deformity  in  the  lumbar  spine. 
(See  Diagnosis  of  Spinal  Caries.)  Pott's  disease  has  also  a  peculiar 
gait,  but  no  limp. 

Prognosis. — The  prognosis  is  grave.  At  the  best  the  disease 
will  be  very  tedious,  and  the  percentage  of  recoveries  is  small. 

Treatment. — Treatment  consists  of  rest  in  the  horizontal  posi- 
tion, with  fixation  by  plaster  bandage,  leather,  felt,  or  similar  jacket 
or  splint.  If  suppuration  ensue  the  abscess  should  be  drained  anti- 
septically.  Encouraging  results  have  been  obtained  by  cutting  down 
upon  and  removing  the  diseased  tissues,  irrigating  thoroughly,  and 
packing  with  iodoform  gauze.  When  the  disease  shows  a  tendency 
to  extend,  notwithstanding  rest  and  general  treatment,  it  is  better  to 


268  SURGICAL   DISEASES    OF   CHILDREN 

interfere  thoroughly  than  to  allow  abscesses  to  burrow  or  suppu- 
ration to  exhaust  the  patient. 

TUBERCULAR    DACTYLITIS    (SPINA    VENTOSA) 

This  is  a  very  common  form  of  tubercular  disease  in  children,  in 
which  the  bones  of  the  fingers  or  toes  or  of  the  metacarpus  or  meta- 
tarsus are  affected.  It  furnishes  a  marked  exception  to  the  rule  that 
tuberculosis  prefers  the  spongy  bones  and  the  epiphyses  of  the  long 
bones  and  seldom  attacks  the  shaft  or  its  medulla. 

It  is  primarily  a  diffuse  central  tubercular  osteomyelitis  of  the 
rarefying  form,  followed  by  osteoplastic  periostitis,  resulting  in 
cheesy  degeneration  within  the  bone  and  deposition  of  new  bone  ex- 
ternally so  that  "  expansion  "  takes  place.  It  begins  as  a  firm  swell- 
ing of  the  phalanx  or  metacarpal  bone,  with  tenderness  but  without 
much  pain.  The  swelling  becomes  large  and  fusiform.  (See  Figs. 
93,  94  and  95.)  "  Abscess  "  forms  and  discharges  through  a  rounded 
opening  with  dark  red  skin  margins.  A  probe  finds  a  comparatively 
large  cavity  within  the  expanded  small-bone.  After  a  tedious  chronic 
course  the  disease  process  may  come  to  an  end,  leaving  a  shortened 


Fig.  94.     Tuberculosis  of  phalangeal  axd  metatarsal  bones. 

and  deformed  finger  or  toe,  or  an  ugly  puckered  scar  upon  hand  or 
foot. 

Dactylitis  is  also  one  of  the  manifestations  of  syphilis.  It  occurs 
far  more  rarely  than  tubercular  dactylitis.  It  is  quite  easy  to  mis- 
take the  syphilitic  for  the  tubercular  disease,  but  there  are  usually 
other  evidences  of  syphilis  and  there  is  more  tendency  to  attack  the 
periosteum  and  less  tendency  to  invade  joints.  The  X-ray  shows 
less  atrophy  in  the  histological  structure  of  the  bone. 

Treatment. — Some  advise  excising  the  bone  early,  but  that 
surely  will  result  in  deformity.     Later,  if  one  attempt  to  scrape  out 


TUBERCULOSIS    OF   BONES   AND   JOINTS  269 

the  diseased  tissue  he  may  find  that  he  has  removed  the  entire  bone, 
or  so  much  of  it  that  it  will  collapse.  Patient,  conservative  treat- 
ment is  best  in  these  cases.  If  treated  early  the  trouble  will  grad- 
ually subside  with  rather  firm  bandaging  upon  a  splint,  and  leave 
very  little  impairment  in  appearance  or  usefulness.  If  not  seen  un- 
til the  swelling  has  opened,  it  is  best  to  give  the  same  plan  of  treat- 
ment a  very  thorough  trial  before  resorting  to  any  attempt  at  eradi- 


FiG.  95.     Tuberculosis  of  metatarsal  bones. 

cation.     Iodoform  and  boric  acid  dressing,  and  firm  pressure,  with 
fixation  and  rest  by  means  of  a  splint,  are  still  the  best  treatment. 

TUBERCULOSIS   OF  THE  STERNO-CLAVICULAR  JOINT 

The  sterno-clavicular  joint  is  occasionally,  though  very  rarely 
in  children,  attacked  by  the  tubercle  bacillus.  When  beginning  in 
bone  it  is  usually  the  clavicle,  though  it  has  been  known  to  begin  in 
the  sternum.  It  may  be  primarily  synovial.  The  symptoms  are  pain, 
swelling,  and  tenderness.  The  pain  may  be  sufficiently  severe  to 
excite  suspicion  of  traumatism;  but  when  the  swelling  appears  it 
is  the  characteristic  tumor  albus,  firm  or  putty-like.  When  the  clavi- 
cle is  attacked  the  swelling  takes  an  oblong  shape.  It  somewhat  re- 
sembles sarcoma,  but  is  more  tender. 

Treatment. — On  account  of  its  situation  it  is  unfortunate  to  have 
suppuration  occur,  for  it  may  take  place  internally  and  descend  into 
the  mediastium  or  pleura,  or  into  the  sheaths  of  the  blood-vessels 
and  involve  the  veins. 

It  is  best,  as  soon  as  a  diagnosis  can  be  made,  to  open  the  swell- 
ing and  eradicate  the  tubercular  infection,  pack  the  cavity,  and  let 
it  close  by  granulation.  Rarely,  complete  removal  of  the  clavicle 
has  been  necessary,  or  a  resection  of  the  sterno-clavicular  joint. 


270 


SURGICAL  DISEASES  OF  CHILDREN 


TUBERCULOSIS  OF  RIBS  AND  OTHER  BONES 

Frequently  in  adults  but  more  uncommonly  in  children,  it  tends 
to  attack  the  costochondral  junction  and  extend  along  the  rib.     It 

may  begin  inside  or  outside 
the  chest,  and,  being  almost 
painless,  attracts  little  at- 
tention until  abscess  occurs. 
(See  Fig.  96.)  One  has 
seen  tuberculosis  of  the  ribs 
with  circumscribed  abscess 
of  the  pleura  which  simu- 
lated empyema.  Ordinarily 
there  is  some  external  swell- 
ing which  has  a  long  diam- 
eter in  the  direction  of  the 
length  of  the  rib.  It  should 
be  thoroughly  cleared  out 
and  packed,  to  heal  by 
granulation. 

Tuberculosis  of  other 
bon^s,  for  instance,  sternum, 
face  or  skull,  occurs  in  chil- 
dren, and  if  untreated  result 
in  tubercular  abscess  with 
consequences  varying  with 
the  situation.  Upon  the 
face  deformity  and  some- 
times disability  result.  •  Of 
the  skull  bones  the  mastoid 
most  frequently  diseased. 
The  frontal,  the  parietal  or 
process  of  the  temporal  is 
occipital,  though  very  rarely  involved  before  the  adult  life,  may  pro- 
duce serious  results.  The  inflammation,  beginning  either  as  a  peri- 
ostitis or  in  the  diploe  may  involve  the  entire  thickness  of  the  bone, 
with  caseation,  suppuration  and  formation  of  small  sequestra.  The 
symptoms  are  pain,  local  tenderness,  swelling,  and  fluctuation  or 
evidences  of  pressure  on  the  brain  if  the  abscess  presses  inward.  Or 
complete  perforation  may  occur.  Syphilis  bears  the  nearest  re- 
semblance. Usually  other  tuberculous  lesions  are  present.  As  a 
rule  tuberculosis  of  facial  and  cranial  bones  should  be  dealt  with 
actively  by  local  eradication  with  the  sharp  spoon,  gouge  or  drill. 


Fig.  96.    Tuberculous  osteo-chon- 
dritis  of  ribs. 


CHAPTER  X 

FRACTURES   AND    SEPARATIONS    OF   EPIPHYSES 

Intra-Uterine  and  Congenital  Fractures — Incomplete  or 
Greenstick  Fractures — Traumatic  Separation  of  Epiphy- 
ses— Refracture  for  Vicious  Union — Fractures  of  the 
Skull — Fractures  of  Nasal  Bones — Fractures  of  the 
Superior  Maxillary  and  Malar  Bones — The  Inferior 
Maxilla — Clavicle — Injuries  of  the  Humerus  near  the 
Elbow — Fracture  above  the  Condyles  of  the  Humerus — ■ 
Separation  of  the  Lower  Epiphysis  of  the  Humerus — T 
OR  Y  Fracture — Fracture  of  the  Internal  Condyle — 
Fracture  of  External  Condyle — Fracture  of  the  Inter- 
nal and  External  Epicondyle — Separation  of  the  Upper 
Epiphysis  of  the  Humerus — Shaft  of  the  Humerus — 
Separation  of  the  Upper  and  Lower  Epiphysis  of  Radius — 
Fracture  of  Shaft  of  Radius  or  Ulna — Fracture  of  Sep- 
aration OF  Olecranon — Fracture  of  Shaft  of  Femur — 
Fracture  of  Shaft  of  Radius  or  L'^'lna — Fracture  or  Sep- 
aration OF  Trochanter  Major — Separation  of  Lower 
Epiphysis  of  Femur — Fractures  of  Shafts  of  Tibia  and 
Fibula — Separation  of  Tibial  and  Fibular  Epiphyses — ■ 
The  Patella  and  Tubercle  of  the  Tibia — Metacarpal  and 
Phalangeal  Fractures — Fractures  of  Ribs — Fractures  of 
Sternum. 

If  certain  anatomical  and  physiological  differences  which  are 
present  in  the  infant  and  child  are  borne  in  mind,  the  variations  in 
their  fractures  as  compared  with  similar  injuries  in  the  adult  are 
readily  accounted  for.  First,  there  is  the  softer  consistencey  of  the 
bones  in  early  life,  due  to  the  lesser  percentage  of  lime  salts  and  the 
greater  relative  proportion  of  animal  matter  which  they  contain. 
Next,  there  is  the  thicker,  stronger,  more  vascular  and  more  easily 
"  stripped  "  periosteum  in  the  young.  A  third  condition  peculiar  to 
the  young  is  the  loose  attachment  of  epiphysis  to  diaphysis  in  the 
long  bones ;  and  a  fourth,  the  smaller,  softer  and  less  powerfully 
contracting  muscles.     There  are  others  of  minor  importance. 

The  different  consistency  of  tlie  bones  renders  them  less  brittle, 
consequently  less  liable  to  comminution,  and  more  liable  to  the  in- 

271 


272  SURGICAL   DISEASES    OF    CHILDREN 

complete  or  the  greenstick  fracture.  The  thick  periosteum,  and,  to 
a  certain  degree,  the  rarity  of  sharp  spHntering,  decreases  the  num- 
ber of  compound  as  compared  with  simple  fractures  and  lessens  the 
liability  of  over-riding  of  the  broken  ends,  and  of  injuries  to  vessels, 
nerves  or  viscera.  (See  Fig.  97.)  But  if  the  violence  is  sufficient  to 
force  the  fragments  through  the  periosteum,  then  the  delicacy  of 
fasciae,  muscles  and  skin  permits  extensive  laceration  of  the  soft 
parts.  The  absence  of  bony  union  between  the  articular  end  and 
the  shaft  in  the  immature  skeleton  permits  a  separation  to  take  place 


Fig.  97.  Fracture  of  radius  and  ulna,  fragments  held  by  periosteum.  So 
little  deformity,  mobility  or  crepitus  that  it  escaped  the  notice  of  an 
experienced  surgeon. 

at  the  epiphyseal  line  as  a  result  of  traumatism  which  in  an  adult 
would  probably  have  caused  a  fracture  or  a  dislocation.  The 
smaller  size  and  weaker  contractile  power  of  the  muscles  modify 
greatly  the  amount  of  the  deformity,  the  tendency  to  which  is  also 
diminished  by  the  more  transverse  line  of  fracture.  A  fracture  of  a 
soft  bone  or  an  epiphyseal  separation  gives  a  crepitus  that  is  less 
sharp  and  grating  than  with  the  dense,  compact,  completely  ossified 
bone  of  the  adult,  or  in  greenstick  fracture  gives  no  crepitus  at  all. 
The  weak  musculature  allows  of  a  readier  reduction  of  the  deform- 
ity ;  but  the  lack  of  the  angularity,  of  the  distinctness  of  the  surface 
landmarks  in  the  undeveloped  bony  and  muscular  systems  of  the 
child,  together  with  the  presence  of  the  thick,  soft  layer  of  subcuta- 
neous fat  and  the  tender  skin  render  it  difficult  to  maintain  accurate 
adjustment  and  perfect  immobilization.  These  difficulties  are  in  no 
way  lessened  by  the  natural  restlessness  and  thoughtlessness  of 
childhood. 

Another  peculiarity  is  the  quick  repair  that  takes  place  under 
ordinarily  favorable  conditions ;  and  still  others,  the  failure  of 
growth  in  length  which  sometimes  follows  injury  at  the  epiphyseal 
line,  and,  contrary  to  Mr.  Holmes'  opinion,  the  unlooked-for  obsti- 


FRACTURES   AND    SEPARATIONS    OF   EPIPHYSES         273 

nacy  of  a  pseudo-arthrosis  in  a  child.  These  pecuhar  conditions 
are  undergoing  continuous  change  from  fetal  to  adult  life,  each 
stage  of  development  being  in  some  particular  point  different  from 
all  the  others.  Certain  morbid  general  conditions,  as  rachitis  and 
fragillitas  ossium,  in  their  connection  with  fractures,  deserve  sep- 
arate consideration.  Fractures  in  utero  and  of  the  new-born  will 
be  grouped  together. 

Diagnosis. — The  diagnosis  is  sometimes  extremely  easy,  as  it 
often  is  in  fracture  in  adults,  but  it  may  be  quite  difficult  in  some 
cases  of  incomplete  or  greenstick  fractures  and  of  epiphyseal  sep- 
aration. Moreover,  fracture  may  be  overlooked  or  unsuspected  in 
infants  or  young  children,  who  give  no  aid  in  locating  pain  and 
drawing  attention  to  the  injury;  and  pain  is  not  as  prominent  a 
symptom  of  fracture  in  the  early  years  of  life  as  it  is  later.  If 
the  child,  through  fear  or  pain,  will  not  allow  a  satisfactory  exam- 
ination, anesthesia  should  be  used;  and  if  there  is  any  doubt  what- 
ever as  to  the  nature  of  the  injury  or  the  probability  of  a  favorable 
result,  it  is  best  for  the  patient,  and  for  the  surgeon's  reputation, 
that  consultation  with  a  surgical  friend  be  had  and  a  few  notes  of 
the  case  be  recorded. 

Treatment  consists  in  prompt  and  accurate  adjustment  and  the 
application  of  fixation  apparatus,  sometimes  with  extension.  Nu- 
merous materials  are  used  for  this  purpose,  the  most  common 
being  binders'  board,  plaster  of  Paris  and  wood,  with  adhesive 
straps,  cotton  and  bandages.  If  the  fracture  is  simple  and  without 
shortening,  not  near  or  into  a  joint,  so  that  little  swelling  is  to  be 
expected,  it  may  be  put  up  in  plaster  from  the  beginning.  If  swell- 
ing is  to  be  expected,  it  would  be  better  to  use  plaster  splints,  held 
in  place  by  a  muslin  roller,  as  this  can  readily  be  removed  for  inspec- 
tion and  adjustment.  Frequently  plaster  is  not  at  hand,  and  binders' 
board  is  usually  obtainable,  and  having  been  cut  to  shape  and  dipped 
in  hot  water  and  applied  over  a  layer  of  cotton,  perhaps  reinforced 
with  a  strip  of  wood  and  held  with  a  bandage,  serves  a  useful  pur- 
pose, either  temporarily  or  flroughout  the  treatment.  Sometimes 
extension  and  counter-extension  are  necessary,  but  less  frequently 
in  children  than  in  adults,  and  very  seldom,  if  ever,  in  infants. 

Amputation  or  excision  should  almost  never  be  resorted  to  with- 
out an  effort  to  avoid  it  and  save  the  limb.  It  is  only  justifiable  if 
the  limb  or  joint  are  crushed  and  pulpified  or  the  main  vessels  and 
nerves  hopelessly  injured.  Comminution  of  bone  and  extensive 
laceration  of  soft  parts  does  not  preclude  the  possibility  of  preserv- 
ing a  useful  member.  The  reparative  power  of  the  young  organism 
often  surprises  those  who  are  not  familiar  with  surgery  among 
children.  If,  after  a  faithful  effort  by  hot  wet  dressings  to  revive 
^nd  maintain  the  vitality  of  the  injured  tissues,  gangrene  super- 


274  SURGICAL   DISEASES    OF    CHILDREN 

venes, '  the   surgeon   cannot   censure   himself,   nor   can   the   child's 
friends  censure  him,  for  sacrificing-  the  limb  to  save  the  life. 

INTRA-UTERINE  AND  CONGENITAL  FRACTURES 

It  is  well  known  that  fractures  may  occur  in  utero  from  vio- 
lence to  the  mother ;  or  in  parturition,  either  by  the  natural  expul- 
sive forces  or  as  an  unintended  result  of  the  efforts  of  the  attendant. 
Intra-uterine  fractures  sometimes  unite  before  birth,  either  in  good 
position  or  in  deformity,  as  it  may  happen,  or  they  may  remain 
ununited  at  birth,  even  though  sufficient  time  had  elapsed.  These 
points  sometimes  have  a  medico-legal,  as  well  as  a  surgical,  interest. 
Fractures  of  the  bones  of  the  skull  may  be  either  linear,  in  the  form 
of  a  gutter  produced  by  the  blade  of  the  obstetric  forceps  or  from 
being  forced  past  an  exostosis  or  the  sacral  promontory;  or  of  the 
spoon-bowl  variety,  from  continued  pressure  upon  one  point.  Any 
of  the  bones  of  the  cranial  vault  may  be  fractured  either  in  spon- 
taneous or  assisted  delivery,  but  the  parietal  most  frequently  suffers 
this  injury.  Quite  frequently  no  symptoms  result  and  no  treatment 
is  necessary  beyond  careful  manipulation  upon  delivery.  But  if 
there  be  pressure  symptoms  due  to  depression  of  bone  or  intra- 
cranial hemorrhage,  trephining  should  be  resorted  to.  This  is  sel- 
dom done.  Often  slight  depressions  disappear  spontaneously  or 
remain,  but  produce  no  symptoms.  However,  the  effects  may  be  so 
late  in  developing  as  not  to  be  attributed  to  their  real  cause.  The 
time  may  come  when  professional  opinion  will  demand  operation  in 
all  cases  of  depressed  bone  or  intra-cranial  hemorrhage  in  the  new- 
born whenever  there  are  enough  symptoms  to  make  a  diagnosis. 
The  lower  jaw  may  be  fractured  or  its  lateral  halves  separated  at 
the  chin  by  efforts  at  extraction.  It  should  be  put  up  in  a  plaster  of 
Paris  or  molded  binder's  board  splint;  or  a  plaster  cast  should  be 
made  and  a  vulcanite  splint  shaped  upon  that.  One  of  the  not  un- 
common injuries  is  separation  of  the  upper  epiphysis  of  the  humerus, 
produced  by  attempts  to  bring  down  the  arm  which  has  remained 
alongside  of  the  head  in  a  head-last  delivery,  or  by  pulling  upon 
an  arm  with  rotation  at  the  same  time.  For  symptoms  and  treat- 
ment see  section  on  separation  of  epiphyses,  and  of  the  special 
bone. 

Fracture  of  the  shaft  of  the  humerus  occurs  in  the  same  way 
as  epiphyseal  separation.  It  should  be  dressed  by  splints  encircling 
the  arm  and  the  member  flexed  to  a  right  angle,  and  fastened  to  the 
side  of  the  thorax  by  adhesive  straps  and  a  bandage. 

Obstetric  fracture  of  the  femur  is  usually  caused  in  attempts 
at  podalic  version  or  in  breech  presentations  during  attempts  to 
bring  down  a  thigh  by  finger,  blunthook  or  fillet.  There  is  very 
little  deformity  or  tendency  to  override.    Union  usually  takes  place 


FRACTURES   AND    SEPARATIONS    OF   EPIPHYSES  275 

in  ten  or  fifteen  days  if  the  limb  is  properly  put  up  at  once,  and 
gives  a  good  result  without  shortening  or  other  deformity.  Binders' 
board  is  always  at  hand ;  or  sheet  vulcanite  can  be  secured,  as  Nan- 
crede  suggests.  Either  of  them,  after  dipping  in  hot  water,  can  be 
modeled  upon  the  limb  and  abdomen,  and  then,  after  careful  adjust- 
ment of  the  broken  ends,  bandaged  on,  or  plaster  of  Paris  can  be 
used,  or  light  wooden  splints  around  the  thigh.  If  the  precaution 
be  taken  to  carry  the  splinting  above  the  hip- joint  to  abdomen  or 
chest,  and  below  the  knee,  a  straight  limb  will  be  obtained.  Some 
prefer  the  suspension  treatment  in  fractures  of  the  thigh,  even  in 
the  new-born.  But  one  has  often  had  results  that  could  not  be 
improved  upon,  and  never  any  bad  ones  from  the  simple  straight 
splinting  without  any  form  of  extension. 

SPONTANEOUS  AND    PATHOLOGICAL   FRACTURES 

Spontaneous  and  pathological  fractures  occur,  but  very  rarely, 
as  a  result  of  muscular  action  or  trifling  accidental  force  acting 
upon  bone  weakened  either  by  local  disease,  such  as  osteitis  or  sar- 
coma, or  a  geneial  disease  like  scurvy  or  rachitis,  osteopsathyrosis, 
and,  still  more  rarely  in  children,  by  osteomalacia,  diabetes  and  the 
osteoporosis  accompanying  central  nervous  disease  and  phospha- 
turia.  It  has  been  reported,  but  must  be  rare  also,  in  hydrocephalus 
and  infantile  paralysis.  Spontaneous  separation  of  epiphysis  occurs 
in  syphilis  in  young  infants ;  it  has  been  mentioned  under  epiphysitis 
and  syphilis.  Epiphysis  and  shaft  reunite  under  anti-syphilitic 
treatment. 

Rickets  and  scurvy  produce  a  friability  of  the  bones  which 
sometimes  leads  to  spontaneous  fracture  or  to  fracture  from  slight 
violence.  Union  is  usually  obtained,  although  it  may  take  place 
slowly,  and  there  may  be  a  larger  callus  than  in  normal  bone. 

Osteopsathyrosis,  a  form  of  fragilitas  ossium,  is  an  hereditary 
disease,  in  which  there  is  a  tendency  to  fracture.  The  nature  of  the 
disease  is  unknown.  It  does  not  present  the  epiphyseal  enlarge- 
ments nor  the  pliability  of  rickets,  nor  the  softness  of  osteo- 
malacia. The  bones  are  small,  and,  being  deficient  in  lime  salts 
without  having  an  increase  of  organic  matter,  they  are  brittle,  and 
repeated  fractures  occur  from  very  slight  violence.  The  muscles, 
fascije  and  ligaments  are  also  lax,  although  the  child  appears  in 
good  health.  There  is  very  little  pain,  swelling,  or  deformity  as  a 
result  of  the  fracture.  The  prognosis  as  to  union  of  the  fracture 
is  good,  but  as  to  the  general  condition  it  is  unpromising.  The 
treatment  is  that  of  any  fracture,  locally,  and  for  the  general  patho- 
logical state,  cod-liver  oil,  phosphorus,  iron,  manganese,  arsenic, 
hypophosphites  of  lime  and  soda,  good  nourishing  food,  and  hygienic 
mode  of  Hfe. 


276  SURGICAL   DISEASES    OF   CHILDREN 

Osteomalacia  is  extremely  rare  in  children.  The  bones  are 
deficient  in  lime  salts,  their  inorganic  matter  having  been  absorbed 
from  the  medullary  surface.  There  is  no  beading  of  ribs  nor  en- 
largement of  epiphyses  of  the  long  bones,  nor  osteoplastic  activity 
of  the  periosteum,  as  in  rickets.  The  bones  are  thus  exceedingly 
soft  and  friable,  and  spontaneous  fractures  occur,  as  well  as  very 
numerous  curvatures.  If  union  takes  place  there  is  superabundant 
callus,  and  if  a  false  joint  is  formed  there  is  little  prospect  of 
its  cure. 

INCOMPLETE  OR  GREENSTICK  FRACTURES 

Incomplete  fracture,  or  fracture  in  which  there  is  not  complete 
solution  of  continuity,  occurs  in  children.  By  this  is  meant  fracture 
in  which  there  is  solution  of  continuity  through  a  part  of  the  bone 
upon  the  convexity,  while  the  remainder  of  the  bone  upon  the  con- 
cavity is  only  bent.  It  is  not  very  apt  to  be  accompanied  by  longi- 
tudinal fracture  or  fissure  of  any  extent. 

A  variety  of  fracture  which  is  far  more  frequent  in  children 
than  in  adults,  though  it  does  occur  in  the  latter,  is  the  true  incom- 
plete, the  ''  greenstick "  fracture,  sometimes  called  infraction,  in 
which  there  is  only  angulation  at  the  seat  of  injury,  but  no  solution 
of  continuity,  unless  the  bent  bone  be  straightened  again,  which 
may  make  it  a  complete  fracture.  The  most  common  situations  of 
this  fracture  are  the  forearm  and  the  clavicle ;  and  more  rarely  the 
arm,  leg,  and  thigh.  In  the  forearm  or  leg  one  bone  may  undergo 
complete,  and  the  other  an  incomplete  or  a  greenstick,  fracture. 
The  deformity  and  tenderness  on  pressure  at  the  angulation  are  the 
only  symptoms,  mobility  and  crepitus  being  absent,  and  deformity 
not  very  marked.  Thus  greenstick  fractures,  if  slight,  are  very 
easily  overlooked  until  the  presence  of  the  callus  or  its  interference 
with  pronation  and  supination,  if  the  injury  is  in  the  forearm,  draw 
attention.     (See  Figs.  98  and  99.) 

The  treatment  of  greenstick  is  the  same  as  for  simple  complete 
fracture.  If  seen  early  the  deformity  should  be  corrected  (even  if 
this  act  completes  the  fracture)  and  the  limb  put  up  in  fixation 
splints.  If  not  seen  until  there  is  considerable  swelling  or  a  callus 
has  formed,  one  has  often  succeeded  in  straightening  the  bone  by 
following  Mr.  Holmes'  advice  and  putting  it  up  in  straight  splints, 
well  padded,  and  readjusting  them  frequently  so  as  to  avoid  ulcera- 
tion from  pressure. 

TRAUMATIC   SEPARATION   OF  EPIPHYSES 

This  occurs,  as  would  be  expected,  much  more  frequently  at 
that  time  of  life  and  stage  of  development  which  find  the  epiphyses 
and  diaphyses  not  yet  made  one  by  bony  union,  as  should  take  place 
in  the  female  at  twenty-two  and  in  the  male  at  twenty-five  years  of 


FRACTURES   AND    SEPARATIONS    OF   EPIPHYSES         27; 

age.  It  has  long-  been  believed  and  demonstrated  by  clinicians  and 
investigators  that  the  line  of  separation  does  not  often  follow  exactly 
the  epiphyseal  line,  but  deviates  into  the  diaphysis  or  into  the  epiphy- 
sis. The  younger  the  patient  the  more  probable  it  is  that  the  sepa- 
ration will  take  place  accurately  in  the  epiphyseal  line;  while  in 


Fig.  98.  Greenstick  fracture  radius  and  ulna.  Brought  for  treatment 
three  weeks  after  the  accident.  Refracture  and  straightenmg  was  nec- 
essary.    Girl  six  years  old. 


Fig.  99.     Greenstick  fracture  both  bones  of  forearm.     Boy  8  years  old. 

patients  approaching  the  age  when  epiphysis  and  diaphysis  are 
joined  by  bone  it  becomes  more  probable  that  a  portion  of  bone  will 
be  torn  off  with  the  cartilage.  So  that  observations  with  the  X-ray 
made  more  recently  only  serve  as  corroborative  evidence.  The  at- 
tempt to  deny  the  propriety  of  classifying  epiphyseal  separations  as  a 
special  variety  of  injury  because  the  fracture  does  not  adhere  pre- 
cisely to  the  epiphyseal  line,  but  has  a  few  granules  or  more  of  bone 
upon  the  separated  cartilage  or  of  cartilage  upon  the  end  of  the  bone, 
has  no  tenable  ground.  And  the  following  opinion,  written  in  1868 
by  Timothy  Holmes,  has  scarcely  been  improved  upon :  "  The  con- 
clusion to  which  my  experience  of  this  injury  would  lead  me  is  that 
fracture  occurs  not  very  rarely  at  or  in  the  immediate  neighborhood 
of  the  epiphyseal  line;  that  the  line  of  fracture  coincides  in  these 


278  SURGICAL   DISEASES    OF   CHILDREN 

cases  partially  with  that  of  the  epiphyseal  cartilage,  but  seldom  com- 
pletely; that  the  general  symptoms  are  therefore  the  same  as  those 
of  fracture,  while  the  special  symptom  must  be  sought  for  from  the 
anatomy  of  each  joint;  and,  finally,  that,  as  the  epiphyseal  cartilage 
is  severely  injured,  loss  of  growth  is  very  liable  to  follow." 

The  injury  is  generally  produced  by  cross-strain.  The  diag- 
nosis is  made  upon  the  history  of  the  injury,  the  deformity,  the  size 
and  shape  of  the  fragment,  the  local  tenderness,  undue  mobility,  loss 
of  function  and  crepitus.  The  displacement  may  "be  so  slight  as  to 
eliminate  it  entirely  from  the  diagnosis,  or  it  may  be  complete. 

The  epiphyses  are  not  very  deep  and  the  fracture  line  is  very 
near  the  joint,  so  that  if  there  is  no  displacement  it  may  be  over- 
looked, or  if  there  is  displacement  it  may  be  mistaken  for  a  disloca- 
tion. The  edges  of  the  fragments  are  less  sharp  in  outline  than 
with  ordinary  fracture.  Crepitus  may  be  absent,  or  very  indis- 
tinct, or  soft,  sometimes  described  as  "  false  "  or  "  dummy  "  crepitus 
or  a  "  mortary  "  feeling. 

The  thick  and  vascular  periosteum  of  a  child  is  very  easily 
separated  from  the  shaft  of  a  bone,  but  is  more  firmly  adherent  to 
the  margins  of  the  articular  cartilages  and  about  the  tendinous  and 
muscular  attachments,  so  that  if  an  epiphysis  is  detached  and  dis- 
placed it  often  carries  with  it  the  periosteum  which  strips  from  the 
shaft,  thus  robbing  it  of  a  portion  of  its  vascular  supply  and  possibly 
resulting  in  necrosis.  Or  this  loosened  periosteum  may,  if  there  is 
great  displacement,  become  interposed  between  the  fragments  and 
prevent  reduction.  Or  if  the  displacement  remains  for  a  time  unre- 
duced, ossification  beneath  the  separated  portion  of  periosteum  may 
produce  a  layer  of  bone  which  renders  reduction  impossible  without 
operation  for  its  removal.  The  liability  of  displacement  lies  not 
only  in  the  degree  and  direction  of  the  violence,  but  in  the  muscular 
attachments  about  the  joint  which  draw  upon  the  fragments. 
Another  danger  is  the  implication  of  the  near-by  joint,  especially 
when  the  epiphyseal  line  lies  within  it.  Suppuration  is  more  com- 
mon after  separation  of  an  epiphysis  than  after  an  ordinary  fracture, 
for  the  same  reasons  that  so  many  inflammations  attack  the  epiphy- 
seal line.  (See  Sections  on  Osteo-Myelitis  and  Epiphysitis.)  The 
danger  of  arrested  growth  in  length  is  to  be  borne  in  mind  and  is  to 
be  explained  to  the  parents.  If  such  arrest  occurs  it  will,  of  course, 
cause  greater  deformity  the  younger  the  child,  and  be  more  marked 
if  thC' injury  be  located  in  one  of  those  epiphyses  which  contribute 
most  to  the  length  of  the  bone ;  namely,  "  the  upper  end  of  the 
humerus  and  tibia  and  the  lower  end  of  femur  and  radius." 
(Stimson.) 

These  injuries  are  more  common  at  the  lower  and  upper  ends 
of  the  humerus,  the  lower  end  of  the  femur,  the  lower  end  of  the 


FRACTURES   AND    SEPARATIONS    OF   EPIPHYSES         279 

radius,  occasionally  at  the  upper  end  of  the  tibia,  and  more  rarely 
elsewhere.  The  authors  vary  as  regards  frequency.  My  own  expe- 
rience  would  place  the   lower  end  of  the   humerus   as   the   most 

frequent. 

REFRACTURE  FOR  VICIOUS  UNION 

Refracture  has  been  alluded  to  under  the  heading  of  greenstick 
fracture  which  has  been  undiscovered  and  been  allowed  to  unite  in 
deformity.  If,  after  greenstick  or  any  other  fracture,  there  is 
deformity  which  seriously  interferes  with  function  or  is  very  un- 
sightl}^  and  is  not  so  near  a  joint  as  to  make  the  refracture  impossible 
without  imperiling  the  joint,  refracture  should  be  undertaken.  With 
the  child  under  anesthesia  it  may  be  found  that  the  union  in  the 
faulty  position  is  not  very  strong.  If  it  resists  safe  efforts  at  refrac- 
ture it  may  be  necessary  to  cut  down  upon  it  and  use  the  saw  or 
osteotome.  Of  course  an  open  wound  is  not  without  some  danger, 
and  cases  have  occurred  of  failure  to  secure  union  after  refracture. 
Refracture  of  one  bone  where  there  are  two — for  instance,  of  radius 
or  ulna — will  not  be  found  an  easy  task.  Nor  will  a  correct  align- 
ment after  it  is  fractured  or  cut  through.  There  is  redundance  of 
bone  at  the  point  of  angulation,  which,  together  with  the  presence 
of  the  sound  bone  in  proximity,  prevents  straightening.  A  knowl- 
edge of  these  difficulties  will  deter  the  surgeon  from  attempting 
interference  in  cases  of  slight  deviations  from  the  correct  line.  In 
growing  bones,  nature  may  do  a  good  deal  to  round  off  angularities 
and  accommodate  deviations,  so  that  function  will  be  less  impaired. 

FRACTURES   OF  THE  SKULL 

These  will  be  considered  in  the  Chapter  on  Malformations, 
Injuries  and  Diseases  of  the  Head  and  Brain. 

FRACTURES  OF  NASAL  BONES 

Fractures  of  nasal  bones  are  not  uncommon,  resulting  from 
direct  violence.  It  is  important  that  they  be  recognized  and  treated 
— not  merely  because  of  the  external  deformity  which  may  result, 
but  because  of  possible  encroachment  upon  the  lumen  of  the  nostrils, 
and  because  the  fracture  may  have  implicated  the  lachrymal  bone  and 
interfere  with  the  nasal  duct.  Hemorrhage  is  apt  to  be  sharp  for  a 
time,  but  usually  does  not  call  for  plugging  the  nares.  Attempts  at 
blowing  the  nose  may  cause  subcutaneous  emphysema.  Effusion  of 
blood  or,  later,  swelling  externally,  and  swelling  and  blood  clot  in 
the  nostrils,  may  obscure  the  conditions.  It  may  be  necessary  to 
give  an  anesthetic  in  order  to  make  a  satisfactory  examination  and 
replace  the  fragments.  A  stiff  probe,  grooved  director  or  the  like, 
passed  into  the  nostrils  is  of  the  greatest  service  in  ascertaining  the 


28o  SURGICAL   DISEASES    OF   CHILDREN 

condition,  and,  used  in  conjunction  with  the  finger  and  thumb  upon 
the  outside,  in  lifting  the  bones  into  place.  If  the  septum  is  dis- 
placed, a  dressing  forceps,  with  each  limb  covered  with  rubber  tub- 
ing, passed  into  both  nostrils  at  once  may  serve  to  replace  it.  The 
nasal  bones  may  usually  be  held  in  position  by  placing  a  small  roll 
of  gauze  or  adhesive  at  each  side  of  the  nose,  with  a  strip  of 
adhesive  crossing  over  all.  If  the  bones  persistently  fall  flat  they 
may  be  held  up  by  passing  a  hare-lip  pin  through,  well  back,  cut- 
ting off  its  ends  and  winding  silk  thread  from  end  to  end  across 
the  nose.  A  rubber  band  has  been  used  for  this,  but  is  not  rec- 
ommended. The  pin  should  be  removed  in  about  a  week.  If  the 
nasal  duct  is  implicated  in  the  break  its  patency  should  be  main- 
tained by  passing  a  probe  each  day  or  two,  or  wearing  a  lead  wire 
stylet  or  silver  canula  during  the  healing.  The  displaced  septum 
may  require  to  be  pinned  in  position  or  held  by  a  vulcanite  tube 
in  either  nostril  or  by  a  small  clamp  devised  for  the  purpose. 

The  nares  will  require  cleansing  daily  with  carefully-warmed 
normal  salt  solution  or  sodium  bicarbonate  solution  of  the  same 
strength.  Great  difficulty  will  be  experienced  in  preventing  the 
child  from  picking  at  or  blowing  the  nose  unless  the  hands  are 
restrained. 

FRACTURE   OF  THE  SUPERIOR  MAXILLARY  AND   MALAR 

BONE 

This  injury  I  have  never  met  but  once.  The  boy  had  fallen 
under  a  wagon.  It  was  said  the  wheel  passed  over  his  chest  and 
head,  and  the  marks  had  that  appearance,  though  it  seemed  almost 
incredible  that  greater  harm  was  not  done.  There  was  contusion 
and  crepitation  at  the  cheek  bone.  He  recovered,  with  slight  depres- 
sion of  the  malar. 

If  the  superior  maxilla  is  fractured  with  displacement  it  is 
recommended  to  support  it  by  bandaging  the  inferior  maxilla  firmly 
against  it  with  a  four-tailed  bandage.  A  dentist  can  often  be  of 
great  assistance  by  making  a  gutta  percha  plate  or  wiring  the  teeth 
so  as  to  steady  the  fragments. 

THE  INFERIOR  MAXILLA 

This  bone  is  much  more  frequently  fractured  than  the  upper 
jaw.  One  has  seen  it  caused  by  a  fall  upon  rafters,  by  an  acci- 
dental blow  with  a  baseball  bat  and  other  direct  violence,  and  the 
alveolar  process  fractured  in  the  hands  of  a  dentist  extracting 
a  tooth. 

The  fracture  is  generally  not  difficult  to  locate,  especially  if 
dentition  is  complete.  A  single  fracture  is  kept  in  adjustment  with- 
out much  trouble.     Double   or  multiple  fractures   cause   difficulty. 


FRACTURES   AND    SEPARATIONS   OF   EPIPHYSES         281 

The  approximation  of  the  lower  and  upper  teeth  is  an  important 
matter  in  this  adjustment.  Ordinarily  it  is  sufficient  to  mold  a 
splint  of  poroplastic  felt  or  leather  to  fit  the  jaw,  and  hold  it  in 
place  with  a  four-tailed  bandage.  Better  than  a  bandage  is  a  snugly 
fitting  muslin  cap,  which  the  child  cannot  displace,  w-ith  sides  ex- 
tending under  and  in  front  of  the  chin.  Or  the  ordinary  four-tailed 
bandage  or  sling  of  the  chin  can  be  covered  with  adhesive  strapping, 
or  supplemented  with  cross  bandages  on  the  head,  sewed  in  place. 
If  waring  of  fragments  is  attempted  the  location  of  the  sacs  of  the 
developing  teeth  should  be  carefully  avoided.  If  there  is  more 
than  one  fracture,  or  difficulty  in  keeping  the  fragments  in  posi- 
tion with  correct  occlusion,  the  assistance  of  a  dentist  should  be 
obtained.  A  wax  impression  is  taken,  from  which  a  gutta-percha 
splint  is  made,  fitting  accurately  between  upper  and  lower  sets  or 
alveolar  processes,  and  held  by  a  stiff  ware  emerging  at  each  angle 
of  the  mouth  and  fastened  upon  the  outside  near  the  rami.  The 
outside  splint  before  described  then  holds  the  lower  jaw  firmly 
closed  upon  the  upper.  Young  children  can  be  fed  through  a  nasal 
tube  passed  into  the  stomach,  or  liquid  refreshment  passed  inside 
the  teeth  to  the  space  behind  the  molars.  Great  care  should  be 
taken  to  keep  the  mouth  cleansed  by  drinking  water  after  feeding, 
and  by  the  use  of  mild  antiseptic  washes. 

CLAVICLE 

Fracture  of  the  clavicle  is  the  most  frequent  fracture  of  child- 
hood. It  is  estimated  that  it  comprises  from  10  to  15  per  cent,  of 
all  fractures,  and  that  one-third  of  them — some  say  one-half  of 
them — are  in  children  under  the  tenth  year.  The  site  is  usually 
somewhere  in  the  middle  third.  It  is  the  most  frequently  over- 
looked of  all  fractures.  Not  uncommonly,  after  a  little  tumble,  the 
child  refuses  to  use  his  hand  or  forearm,  and,  after  the  mother  has 
examined  these  and  found  nothing  w-rong,  his  crying  is  attributed 
to  fright  or  peevishness.  Or,  perhaps,  the  "  sprained  "  arm  is  put 
in  a  sling  and  the  injury  not  located  until,  in  about  a  week,  the 
enlargement  of  callus  appears.  Even  when  examined  by  a  surgeon 
a  simple  fracture,  which  did  not  tear  the  periosteum,  or  a  greenstick 
fracture  is  easily  overlooked. 

In  infants  and  young  children  a  sufficient  dressing  is  a  ban- 
dage W'hich  holds  the  extremity  snugly  against  the  thorax,  with  the 
hand  toward  the  opposite  shoulder.  Cotton  should  be  placed  be- 
tween the  limb  and  the  chest  and  drying  pow^der  sifted  in,  lest 
chafing  occur,  but  no  axillary  pad  is  necessary.  In  two  or  three 
weeks  a  sling  is  sufficient.  In  older  children,  Sayre's  method  may 
be  employed.  A  wide  strap  of  adhesive  is  sewn  around  the  upper 
arm,  with  its  adhesive  side  out.    The  arm  is  then  drawn  backward, 


282  SURGICAL   DISEASES    OF   CHILDREN 

while  the  strapping  is  carried  across  the  back  and  around  the  chest, 
adhering  to  the  skin,  and,  passing  under  the  elbow,  it  is  sewn  to 
the  encircling  strap  in  the  middle  of  the  back.  The  elbow  is 
drawn  firmly  forward  against  the  chest.  A  thin  pad  is  introduced, 
to  the  axilla  and  the  hand  carried  up  as  near  as  possible  toward 
the  opposite  shoulder.  A  second  strap  of  adhesive  has  a  slit  in 
its  middle,  which  receives  the  point  of  the  elbow,  and  the  straps 
are  carried  over  the  sound  shoulder,  where  they  overlap.  A 
roller  bandage  is  then  applied  over  all.  Whether  the  humerus 
really  acts  as  a  lever  to  draw  the  shoulder  outward  and  pre- 
vent overriding  of  the  fragments  may  be  questioned,  but  this 
dressing  certainly  effects  fixation  as  satisfactorily  as  any  that 
is  easily  applied.  A  perfect  result  without  a  small  enlargement 
at  the  site  of  the  fracture  should  not  be  promised.  Three  weeks 
is  generally  sufficient  time  to  secure  union. 

INJURIES  OF  THE  HUMERUS  NEAR  THE  ELBOW 

These  are  very  common  and  very  important,  being  more  nu- 
merous than  injuries  of  any  other  portion  of  the  bone,  and,  together 
with  dislocations  of  the  elbow,  constituting  a  large  percentage  of 
the  bone  accidents  which  bring  the  surgeon  difficulty  and  anxiety. 

They  are  grouped  together  on  account  of  their  being  all  located 
so  near  the  elbow  and  so  often  requiring  differentiation.  I  have 
made  no  attempt  to  arrange  them  in  the  order  of  their  relative  fre- 
quency, for  authors  are  not  agreed  upon  that  point,  but  only  with 
a  view  to  convenience  in  description. 

At  birth  the  lower  extremity  of  the  humerus  is  cartilaginous. 
Ossification  of  the  epiphysis  commences  at  the  end  of  the  second 
year  in  the  capitellum,  and  this  center  forms  the  greater  part  of 
the  articular  surface  of  the  bone.  Ossification  begins  in  the  internal 
condyle  in  the  fifth  year,  and  in  the  trochlea  at  the  twelfth ;  in  the 
external  condyle  about  the  thirteenth  year.  The  ossific  centers  of 
the  capitellum,  trochlea,  and  external  condyle  join,  and  then  all 
three,  as  one,  unite  with  the  shaft  at  the  sixteenth  or  seventeenth 
year.     Finally  the  inner  condyle  joins  at  the  eighteenth  year. 

One  should  be  perfectly  familiar  with  the  appearance  and  "  feel  " 
of  this  troublesome  joint  in  all  its  positions,  for  it  often  presents  the 
most  puzzling  conditions  in  cases  of  injury. 

As  in  all  examinations  where  it  is  possible,  the  affected  member 
should  always  be  compared  with  its  sound  mate.  The  most  useful 
maneuver  in  examining  an  injured  elbow  is  to  ascertain  the  relative 
positions  of  the  olecranon  and  the  condyles.  If  the  end  of  the 
thumb  be  placed  upon  one  epicondyle  and  the  middle  finger  upon 
the  other,  with  the  end  of  the  index  finger  upon  the  tip  of  the 
olecranon,  whil,e  the  joint  is  alternatively  flexed  and  extended  and 


FRACTURES   AND    SEPARATIONS    OF    EPIPHYSES  283 

held  at  a  right  angle,  these  positions  can  be  readily  appreciated. 
It  is  noted  that  when  the  joint  is  fully  extended  the  end  of  the 
olecranon  is  midway  between  the  two  epicondyles  and  all  these  three 
are  in  a  straight  line.  But  if  the  joint  is  flexed  to  a  right  angle  the 
point  of  the  olecranon  forms  the  obtuse  apex  of  a  triangle.  Notice 
whether  either  of  the  condyles  can  be  moved  independently  of  the 
other.  Now,  if  the  distance  between  the  two  epicondyles  is  too 
great,  as  compared  with  the  normal  elbow,  evidently  there  is  a 
fracture  somewhere  between  them.  And  if,  besides,  the  olecranon 
has  ascended  from  its  point  of  the  triangle  it  has  entered  this  split 
between  the  condyles.  But  if  they  are  not  too  wide  apart,  but  the 
tip  of  the  olecranon  has  ascended,  it  has  parted  company  wath  the 
ulna.  The  relative  position  of  these  three  points,  the  condyles  and 
olecranon  as  a  group,  to  the  long  axis  of  the  shaft  of  the  humerus 
should  be  noticed — whether  they  are  forward  or  backward  from  its 
axis,  or  deviate  laterally.  By  grasping  the  shaft  of  the  humerus 
in  one  hand,  while  still  holding  the  condyles  in  the  other,  abnormal 
mobility  may  be  tested,  and  if  fracture  or  separation  of  epiphysis 
exists,  crepitation  may  be  detect,ed.  The  position  of  the  head  of 
the  radius  should  be  located ;  flexion  and  extension,  pronation  and 
supination  all  be  systematically  examined.  At  the  risk  of  being 
tiresome  I  here  venture  to  repeat  the  caution  that  in  any  possible 
doubt  or  difficulty  about  an  injured  bone  or  joint,  a  friend  should 
be  called  in  and  an  anesthetic  administered  for  the  examination  and 
dressing ;  and  a  few  notes  made  of  the  condition  and  subsequ,ent 
treatment.  Many  a  practitioner  has  regretted  omitting  such  thor- 
oughness and  precaution. 

I  cannot  agree  with  those  who  advise  waiting  until  the  swell- 
ing subsides  before  attempting  a  thorough  examination,  or  before 
reducing  and  applying  splints.  Instead  of  subsiding,  even  with 
the  use  of  evaporating  lotions  and  the  like,  the  swelling  may  become 
more  dense  and  brawny,  rendering  the  landmarks  more  obscure 
than  ever  and  remaining  until  the  formation  of  callus  has  begun 
with  the  deformity  uncorrected. 

The  injury  of  the  humerus  near  the  elbow  (if  dislocation  be 
excluded)  may  be  a  fracture  above  the  condyles;  it  may  be  a  sep- 
aration of  the  lower  epiphysis,  and  either  of  these  may  be  made  a 
T  fracture  by  a  v.ertical  break  extending  into  the  joint;  it  may  be 
a  fracture  of  the  internal  or  of  the  external  condyle,  or  of  the 
internal  or  of  the  external  epicondyle,  or  through  the  trochlea,  or 
through  tlT,e  capitellum. 

FRACTURE    ABOVE   THE    CONDYLES    OF   THE    HUMERUS 

Violence  acting  near  the  lower  end  of  the  bone,  either  forward 
or  backward,  or  with  the  elbow  over-extended,  or  by  torsion,  may 


284 


SURGICAL   DISEASES    OF   CHILDREN 


produce  this  fracture.  The  fracture  may  be  oblique  in  any  direc- 
tion or  nearly  transverse,  and  the  deformity  will  vary  somewhat 
accordingly. 

Symptoms  and  Diagnosis. — The  symptoms  are  deformity,  loss 
of  function,  undue  mobility,  crepitus  and  pain.  The  deformity  is 
usually  a  projection  at  the  back  of  the  elbow,  caused  by  the  lower 

fragment.  (See  Fig.  100.) 
Rarely  the  obliquity  may  be 
downward  and  backward 
and  cause  a  projection  of 
the  upper  fragment  in  the 
same  direction,  while  the 
lower  fragment  points  for- 
ward and  upward. 

The  injury  will  somewhat 
resemble  dislocation,  espe- 
cially when  the  point  of  the 
elbow  projects  backward 
from  the  line  of  the  hu- 
merus. But  it  will  at  once 
be  perceived  that  the  posi- 
tion of  the  olecranon,  with 
relation  to  the  condyles,  has 
not  changed ;  it  remains  the 
same  as  in  the  sound  elbow ; 
and  that  the  abnormal  angu- 
lation is  not  in  the  joint,  but 
perceptibly  above  the  joint, 
and  that,  upon  traction  upon 
the  flexed  forearm  and 
pressing  the  elbow  forward, 
the  deformity  can  easily  be  reduced,  but  immediately  returns  upon 
release  of  the  traction.  There  is  also  abnormal  lateral  mobility, 
and  perhaps  crepitation. 

Treatment. — The  sooner  the  fracture  is  reduced  and  put  up 
in  sphnts  the  better.  The  proper  application  of  a  padded  splint 
bandaged  in  place  does  much  to  prevent  swelling  and  inflammation, 
and  does  it  better  than  liniments  or  lotions.  The  pressure  does 
some  of  this  work,  but  the  fixation — the  enforcement  of  rest  upon 
the  irritated  tissues — does  more.  Gerster  -uses  an  Esmarch  ban- 
dage, the  patient  being  anesthetized,  to  rapidly  reduce  the  swelling 
so  that  a  diagnosis  can  be  made,  and  then  puts  up  the  fracture. 
Swelling  that  can  be  removed  by  an  elastic  bandage  in  the  course 
of  a  few  minutes  can  be  prevented,  or,  if  present,  more  gradually 
removed  by  the   supporting  pressure   of   a   well-applied   dressing. 


Fig.  100.     Fracture  of  right  humerus 
above  the  condyles.    Boy  aged  5  years. 


FRACTURES    AND    SEPARATIONS    OF    EPIPHYSES  285 

The  therapeutic  effect  of  cold  can  be  utilized  if  necessary  by  the 
use  of  ice  bags  applied  outside  of  the  dressings. 

Very  numerous   methods   for  the  treatment  of   supracondylar 
fractures  of  the  humerus  are  recommended.     They   vary  all   the 
way  from  double  splinting  of  arm  and  forearm  with  weight  exten- 
sion— the  patient  kept  in  bed — to  laying  the  arm  on  a  pillow  and 
putting  on  no  apparatus  at  all.     The  position  advised  also  varies 
from  complete  extension,  through  moderate  flexion,  flexion  to  right 
angle,  up  to  forced  flexion.     The  limits  of  time  and  space  preserve 
us  from  a  discussion  of  all  these.     No  doubt  excellent  results  have 
been  obtained  by  every  one  of  the  different  plans.     If  the  surgeon 
examines  carefully  and  perceives  the  condition,  and  adapts  means  to 
meet  the  indication,  rather  than  by  rule,  he  will  usually  succeed. 
In  my  own  practice  I  prefer,  in  the  majority  of  these  cases,  the 
anterior  hinged  splint,  reaching  from  the  level  of  the  armpit  to  the 
fingers,  with  a  molded  or  sometimes  a  straight  back  splint  for  the 
arm.     The  splint  is  smoothly  rounded  at  the  angle  and  well  padded 
along  its  whole  bearing  surface.     Two  adhesive  straps  are  placed 
along  the  anterior  and  two  along  the  posterior  aspect  of  the  fore- 
arm, adhering  as  far  as  the  wrist,  their  free  ends  extending  beyond 
the  fingers.     A¥ith  the   elbow   three-fourths   extended,   the  hinged 
splint  is  laid  upon  its  anterior  surface  and  the  upper  end  of  the 
splint  strapped  with  wdde  adhesive  to  the  upper  arm.     Seizing  the 
condyles  with  thumb  and  fingers,  the  fracture  is  reduced  and  frag- 
ments adjusted.     By  pulling  forward  upon  the  forearm  and  press- 
ing backward  upon  the  splint  this  adjustment  is  maintained,  while 
the  extension  straps  upon  the  forearm  are  tied  over  notches  in  the 
lower  end  of  the  splint.    By  flexing  the  extremity  toward  the  right 
angle   any    desired   degree   of   extension    can   be    produced.     The 
back  splint  is  then  put  in  place  and  held  by  two  or  three  encir- 
cling straps  of  adhesive.     The  whole  extremity  is  carefully  ban- 
daged,   from   fingers   to   armpit.      If   there   is   much    contusion    or 
swelling  or  joint  injury  the  patient  is   put  to  bed,  with  the  arm 
elevated  on  a  pillow,  with  an  ice  bag  beneath  and  one  on  top  of 
the  elbow.     Ordinarily  he  goes  about  wuth  his  arm  in  a  sling,  elbow 
at  right  angles.     The  bandage  can  be  removed  and  the  limb  in- 
spected at  any  time  without  removing  the  splints,  and  then  reband- 
aged.     There  is  no  hurry  about  passive  movements.     Three  weeks 
or  four  is  soon  enough,  and  by  that  time  the  limb  is  nearly  well. 

SEPARATION  OF  THE  LOWER  EPIPHYSIS  OF  THE  HUMERUS 

This  injury  is  more  apt  to  occur  in  children  under  four.  As 
Mr.  Owen  says,  it  seems  to  take  the  place,  to  some  extent,  of  dis- 
location or  fracture,  the  junction  of  epiphysis  and  diaphysis  yielding 
more  readily  than  .either  the  bone  or  the  ligaments.     But  it  happens 


286  SURGICAL    DISEASES    OF    CHILDREN 

Up  to  the  thirteenth  or  fourteenth  year,  becoming  less  frequent  as 
the  period  of  complete  ossific  union  is  approached.  It  appears,  too, 
that  as  age  advances  the  separated  portion  is  less  likely  to  be  the 
entire  epiphysis ;  in  older  children  it  may  be  only  the  external  con- 
dyle and  capitellum. 

The  symptoms  of  separation  of  the  lower  epiphysis  are  the 
same  as  those  of  supracondylar  fracture,  with  displacement  of  the 
lower  fragment  backward,  excepting  that  the  angulation  is  imm,e- 
diately  above  the  joint  (the  epiphysis  being  but  a  thin  layer  extend- 
ing no  higher  than  the  epicondyles),  and  the  margins  of  the  frag- 
ments are  less  sharp,  abnormal  mobility  less  evident,  and  crepitation 
less  distinct.  The  injury  bears  some  resemblance  to  dislocation  of 
the  forearm  backward.  But  the  olecranon  and  condyles  keep  their 
normal  relative  positions.  The  backward  displacement  can  readily 
be  corrected  by  holding  the  shaft  of  the  humerus  in  one  hand  and 
bringing  the  condyles  and  olecranon  downward  and  forward — but 
it  will  not  stay  corrected.  At  the  same  time  one  notices  the  abnor- 
mal lateral  mobility  and  the  crepitation.  Epiphyseal  separation 
occasionally  presents  so  little  displacement  and  consequent  deform- 
ity, such  slight  mobility  and  doubtful  crepitation  that  it  is  likely 
to  be  overlooked  or  considered  a  sprain  until  the  presence  of  callus, 
interfering  with  motion,  reveals  the  diagnosis.  In  any  case  of  doubt 
it  is  better  to  treat  the  case  as  one  of  epiphyseal  separation  or  frac- 
ture than  to  declare  them  positively  not  present.  This  fracture  is 
put  up  just  like  the  supracondylar,  but  is  more  easily  held  in  place. 
It  can  be  held  by  a  molded  splint  of  binders'  board,  felt  or  plaster. 
I  usually  use  the  anterior  hinged  splint,  sometimes  omitting  the 
traction  straps  on  the  forearm  and  using  molded  binders'  board  as 
a  back  splint.  Union  takes  place  somewhat  more  quickly  than  with 
supracondylar  or  a  shaft  fracture,  and  passive  motion  may  be  begun 

somewhat  earlier. 

T  OR  Y  FRACTURE 

When,  in  addition  to  a  supracondylar  fracture  or  a  complete 
epiphyseal  separation,  there  is  a  vertical  fracture  into  the  joint  it 
is  called  a  T  or  Y  fracture,  according  to  the  direction  of  the  upper 
line  of  cleavage.  In  addition  to  the  symptoms  of  supracondylar 
fracture  or  epiphyseal  separation  we  have  a  widening  across  the 
joint.  The  condyles  are  too  far  apart,  and  they  move  independently 
of  one  another  and  of  the  shaft.  Sometimes  the  fragments  are 
separated  and  the  ulna  is  between  them,  shortening  the  upper  arm 
and  greatly  widening  the  elbow.  The  joint  is  filled  with  blood  and 
swells  rapidly,  distorting  its  outlines.  There  is  free  mobility  and 
great  pain.  With  this  extensive  traumatism  there  is  apt  to  be  injury 
of  nerve  trunks  or  vessels.  An  anesthetic  is  always  necessary  in 
this  fracture.     It  is  put  up  with  the  anterior  hinged  splint,  the 


FRACTURES   AND    SEPARATIONS    OF    EPIPHYSES  287 

adhesive  extension  on  the  forearm  like  the  supracondylar  fracture, 
but  with  a  molded  back  splint  well  up  the  arm  and  down  on  the 
forearm,  coming  round  from  behind.  Care  should  be  taken  to 
have  the  splint  not  too  wide  at  the  joint,  for  when  the  forearm  is 
pulled  down  and  the  separated  condyles  pressed  together,  they  must 
be  held  together  by  the  molded  back  splint,  which  extends  forward 
to  cover  them.  This  is  the  only  elbow  fracture  which  is  at  all  likely 
to  need  weight  or  other  extension,  and  it  can  be  used  if  shortening 
is  not  overcome.  But  I  have  never  seen  a  case  in  a  child  in  which 
a  good  position  could  not  be  maintained  and  a  satisfactory  result 
secured  by  the  method  here  described.  Elevation  and  ice  bags  are 
in  order  for  some  days. 

In  these  fractures,  near  and  into  joints,  there  has  been  much 
discussion  concerning  the  time  to  begin  passive  motion.  After 
considerable  observation  on  this  point,  my  own  conclusion  is  that  to 
begin  passive  motion  before  union  is  sufficiently  firm  not  to  be  dis- 
turbed by  it,  and  the  inflammation  so  far  subsided  as  not  to  be 
re-excited  by  it,  is  a  mistake.  It  only  leads  to  more  callus,  inflam- 
matory exudate  and  scar  tissue,  and  invites,  rather  than  averts, 
ankylosis.  Four  weeks  is  probably  soon  enough  to  begin  it.  But 
if  it  can  be  done  without  pain  it  can  be  begun  in  three  weeks. 
Splints  are  used  four  to  six  we,eks.  With  the  hinged  splint  the 
straps  and  bandages  can  be  slightly  loosened  and  the  joint  slightly 
flexed  or  extended  upon  alternate  days,  the  desired  angle  being 
maintained  by  the  adjustment  of  the  sling.  If,  after  a  few  weeks 
more,  there  seems  to  be  fibrous  ankylosis,  an  anesthetic  may  be 
given  and  the  adhesions  broken.    But  this  is  seldom  needed. 

FRACTURE  OF  THE  INTERNAL   CONDYLE 

The  line  of  fracture  begins  above  or  upon  the  internal  epi- 
condyle  or  epitrochlea  and  extends  downward  and  outward  to  the 
articulating  surface  of  the  trochlea.  Crepitus  is  usual.  Swelling 
may  be  greater  on  the  injured  side,  but  soon  becomes  general.  The 
most  characteristic  symptom  is  independent  mobility  of  the  condyle. 
Lateral  mobility  of  the  forearm  is  sometimes  noticed,  and  the  frag- 
ment may  push  up  higher  than  its  proper  position.  The  fragment 
remains  attached  to  the  olecranon  unless  there  is  also  dislocation, 
which  may  occur.  There  is  usually  not  enough  displacement  to 
disturb  very  noticeably  the  relative  positions  of  the  condyles  and  the 
olecranon.  It  is  said  that  late  displacement  may  occur  by  pushing 
up  of  the  fragment  and  the  ulna  by  a  sling,  and  thus  adduction  of 
the  forearm  may  be  produced.  But  this  may  be  due  rather  to 
stunted  growth  on  that  side  of  the  bone  through  injury  of  the 
cartilage.     (Stimson.) 

Treatment  is  by  a  molded  splint  to  hold  the  condyle  outward, 


288  SURGICAL   DISEASES    OF   CHILDREN 

but  not  to  press  it  upward.  The  joint  is  placed  at  a  right  angle  and 
the  molded  posterior  elbow  splint  embraces  both  the  lower  two- 
thirds  of  the  arm  and  the  entire  forearm,  bandaged  snugly  in  posi- 
tion. A  plaster  of  Paris  roller  should  not  be  used  at  first,  lest 
swelling  render  it  too  tight.  The  arm  is  carried  in  a  sling,  but  the 
sling  does  not  include  the  elbow.  After  about  three  weeks  the 
splint  may  be  left  off  or  worn  but  loosely  for  protection.  Three 
weeks  is  plenty  soon  for  passive  movements.  The  sling  may  be 
discontinued  in  about  four  weeks. 

FRACTURE  OF  EXTERNAL  CONDYLE. 

This  is  a  common  injury  in  children.  The  fracture  extends 
from  above  or  upon  the  external  epicondyle  downward  and  inward 
to  the  articulating  surface.  There  are  independent  movement  and 
crepitus,  elicited  by  moving  the  external  condyle  while  the  humerus 
is  held.  The  condyles  are  too  wide  apart.  The  fragment  adheres 
to  the  radius  and  ulna  unless  there  is  dislocation,  and  it  is  very  easy 
to  cause  displacement  of  the  fragment  by  movements  of  the  fore- 
arm. Swelling  appears  first  upon  the  outer  side,  but  soon  becomes 
general  about  the  joint.  Occasionally  the  fragment  is  displaced  by 
rotation  and  is  almost  impossible  to  reduce.  It  may  also  either  be 
pushed  up  the  arm  or  fail  partially  in  its  after  development  and 
occasion  abduction  of  the  forearm. 

It  should  be  very  carefully  reduced  and  a  posterior  molded 
splint  apphed  as  described  for  fracture  of  the  internal  condyle. 

FRACTURE  OF  THE  INTERNAL  EPICONDYLE 

This  is  an  injury  more  common  in  children  than  in  adults,  and 
occurs  from  falls  upon  the  elbow,  and  in  dislocations  from  the  pull 
of  the  attached  muscles.  The  ulnar  nerve  may  be  injured  at  the 
same  time,  or  may  afterward  be  pressed  upon  by  swelling  or  by 
callus.  Swelling  and  crepitus  are  common.  There  may  not  be 
great  displacement  unless  the  injury  accompanies  dislocation,  or 
the  joint  be  fully  extended. 

The  fragment  is  so  small  that  it  is  hardly  possible  to  reduce 
it  or  to  hold  it  in  exact  position  after  reduction.  But  if  the  joint  is 
at  a  right  angle  there  is  not  much  displacement  of  the  fragment. 
The  joint  should  be  flexed  to  a  right  angle  and  put  up  in  a  fixation 
splint.  Any  fixation  splint  will  serve ;  the  anterior  angular  or  the 
posterior  molded  are  commonly  applied  if  at  hand.  In  fractures  of 
the  epicondyles.  as  well  as  other  injuries  about  the  elbow  in  chil- 
dren, I  have  often  improvised  a  splint  from  a  pasteboard  box.^  The 
box  is  cut  into  two  right-angled  triangular  halves  and  their  ends 

1  Cleveland  Medical  Gazette,  Jan.,   1893. 


FRACTURES    AND    SEPARATIONS    OF    EPIPHYSES  289 

trimmed  to  the  proper  length  for  arm  and  forearm.  The  two  angu- 
lar portions  are  nested  together,  thus  doubling  the  strength.  If  de- 
sired, a  corner  is  cut  from  the  lid  of  the  box  and  applied  on  the 
other  side  of  the  elbow.  Another  angle  of  pasteboard  can  be  applied 
anteriorly  if  necessary.  If  there  are  symptoms  of  pressure  upon  the 
ulnar  nerve  there  should  not  be  too  great  haste  to  cut  down  upon  it. 
With  the  subsidence  of  the  inflammation  and  the  removal  of  callus 
these  symptoms  may  disappear.  Union  is  obtained  in  about  two  or 
three  weeks. 

FRACTURE  OF  THE  EXTERNAL  EPICONDYLE 

This  takes  place  less  frequently  than  that  of  the  internal,  and 
more  frequently  in  children  than  in  adults.  A  molded  binders' 
board,  or  pasteboard  box  splint,  securing  immobilization  for  a  couple 
or  three  weeks,  will  be  all  that  is  necessary. 

SEPARATION  OF  THE  UPPER  EPIPHYSIS  OF  THE  HUMERUS 

This  injury  has  been  referred  to  as  an  obstetric  accident,  pre- 
senting in  the  new-born,  but  it  also  occurs  later  as  a  result  of  a  blow 
or  a  fall  with  the  arm  back  of  the  axillary  line,  or  by  pulling  the 
arm  upward  and  backward.  It  is  not  a  very  common  accident.  The 
head  only  or  the  entire  epiphysis  may  be  separated.  Complete 
displacement  does  not  readily  take  place. 

The  elbow  projects  somewhat  backward  and  outward,  and  a 
protrusion  can  be  felt  under  the  coracoid  process.  This  is  the  lower 
fragment,  which  is  pulled  inward  and  forward  by  muscular  action. 
There  is  slight  flattening  of  the  outer  aspect  of  the  upper  arm,  but 
no  distinct  depression  under  the  point  of  the  shoulder.  The  head 
of  the  bone  can  usually  be  felt,  and  on  moving  the  arm  the  shaft  may 
be  found  to  move  separately  with  the  production  of  soft  crepitus. 
The  edges  of  the  .fragments  may  be  felt,  but  are  more  smooth  or 
rounded  than  those  of  a  fracture.  But  the  symptoms  are  not  always 
so  definite. 

If  complete  displacement  of  the  fragment  has  taken  place,  re- 
duction may  not  be  easy.  It  may  be  facilitated  by  strongly  abduct- 
ing the  arm  and  making  traction,  and  then  manipulating  the  frag- 
ments. Usually  displacement  is  not  complete,  and  yet  it  is  difficult 
to  maintain  exact  apposition.  However,  the  functional  result  is 
usually  good  in  these  cases.  An  inside  splint  should  be  fitted  to 
extend  from  the  elbow  high  into  the  axilla ;  this  should  be  well 
padded.  A  shoulder  cap  of  binders'  board,  plaster,  felt,  or  leather, 
with  the  arm-part  extending  nearly  to  the  elbow,  should  be  applied, 
and  the  two  splints  and  arm  and  shoulder  firmly  fixed  with  adhesive 
straps.     The  elbow  should  be  conveniently  flexed,  laid  comfortably 


290  SURGICAL   DISEASES    OF   CHILDREN 

at  the  side  of  the  thorax,  a  layer  of  cotton  or  linen  intervening  and 
having  the  hand  toward  the  opposite  shoulder,  and  should  be  snugly 
bandaged  in  that  position.  Drying  powder  can  be  sifted  within  the 
dressings  from  time  to  time,  or  the  chest  bandage  changed  if  nec- 
essary, and  the  skin  made  comfortable.  The  splints  are  worn  in 
this  position  ten  to  twelve  days  in  a  new-born  babe,  or  four  weeks 
in  an  older  child. 

SHAFT    OF    THE    HUMERUS 

Fractures  of  the  shaft  of  the  humerus  are  by  no  means  as 
common  as  fractures  of  the  lower  end  of  the  bone  and  present  only 
such  differences  from  similar  injuries  in  adults  as  are  common  to  all 
fractures  in  children,  as  described  in  the  opening  of  this  chapter. 
The  diagnosis  and  reduction  usually  present  no  difficulty.  The 
padded  anterior  angular  and  the  posterior  straight,  or  a  molded 
splint,  held  by  a  few  encircling  straps  of  adhesive  plaster,  and  a 
roller  bandage  over  all,  fix  the  bone  sufficiently.  With  the  elbow 
flexed  at  a  right  angle  the  extremity  is  carried  in  a  sling.  From  ten 
days  or  tv/o  weeks  in  the  new-born  to  three  or  four  weeks  in  chil- 
dren gives  good  union. 

SEPARATION   OF  LOWER  EPIPHYSIS   OF   RADIUS 

This  is  not  an  uncommon  injury  in  the  young.  It  takes  the 
place  of  Colles'  fracture  of  adults,  which  it  much  resembles.  The 
line  of  separation  may  follow  the  epiphyseal  line  quite  closely  or  it 
may  angle  somewhat  into  the  radial  shaft.  It  is  usually  caused  by 
a  fall  upon  the  palm.  The  lower  fragment,  the  epiphysis,  projects 
backward;  the  separated  end  of  the  diaphysis  projects  forward. 
Pronation  and  supination  are  prevented.  Flexion  and  extension  of 
the  hand  are  painful.  The  phalanges  can  be  moved  voluntarily. 
The  periosteum  adheres  to  the  epiphysis,  but  is  stripped  up  from 
the  posterior  surface  of  the  radius,  and  by  its  tension  helps  to  main- 
tain the  position  of  the  fragments  in  deformity.  If  left  in  this  position 
a  layer  of  bone  would  be  produced  between  the  periosteum  and 
the  end  of  the  shaft,  which  would  prevent  subsequent  reduction. 
The  diagnosis  is  made  from  the  deformity  and  loss  of  function. 
Crepitation  can  readily  be  elicited  if  necessary. 

Reduction  is  effected  by  over-extending  the  hand,  traction, 
pushing  the  epiphysis  forward  while  the  lower  end  of  the  shaft  is 
pushed  backward,  then  straightening  or  flexing  the  hand.  There 
are  many  good  splints  and  dressings.  The  ready-made  splints  sel- 
dom fit  children.  As  good  a  dressing  as  any  is  a  straight,  flat  pos- 
terior splint  from  well  up  on  the  forearm  to  the  metacarpo-phalan- 
geal  articulation,  with  a  molded  pasteboard  splint  anteriorly  extend- 
ing from  the  sarne  distance  above  down  to  the  middle  of  the  palm. 


FRACTURES   AND    SEPARATIONS    OF    EPIPHYSES  291 

The  splints,  after  being  encircled  with  three  or  four  adhesive  straps, 
are  bandaged  from  the  hand  up.  Then  the  hand  is  gently  closed 
and  bandaged  in  that  position.  This  prevents  finger  movements 
which  are  painful  and  quiets  the  muscles.  In  a  week  or  so  the  fin- 
gers and  thumb  are  given  freedom.  Union  is  complete  in  three  or 
four  weeks,  and  there  is  no  trouble  about  stiffness  of  the  fingers 
or  wrist.  But  there  may  be  interference  in  the  growth  of  the 
radius  in  length.  And  parents  should  be  informed  concerning  this 
possibility,  lest  such  a  result  later  be  charged  to  the  surgeon.     Fig. 


Fig.  ioi.  Retardation  of  growth  of  radius  in  length  by  injury  of 
EPIPHYSIS.  Forearm  of  man  aged  60,  showing  result  of  injury  of  lower 
epiphysis  of  radius  by  a  fall  at  the  age  of  thirteen  years. 

IOI  shows  the  result,  in  a  man,  of  an  injury  of  the  epiphyseal  car- 
tilage of  the  lower  end  of  the  radius,  received  when  he  was  a  boy 
of  thirteen  years. 

SEPARATION  OF  UPPER  EPIPHYSIS  OF  RADIUS 

This  is  said  to  occur.  I  have  never  recognized  it.  Most  of 
the  descriptions  correspond  to  what  seems  more  probably  the  ordi- 
nary subluxation  of  the  radial  head,  which  will  be  described  under 
dislocations. 

FRACTURE  OF  SHAFT  OF  RADIUS  OR  ULNA 

Fractures  of  shaft  of  radius  or  ulna  or  of  both  bones  may 
occur,  by  direct  violence,  as  by  the  patient  or  another  person  or  a 
weight  falling  upon  the  forearm,  or  by  indirect  violence.  Twisting 
the  forearm  into  .extreme  pronation  or  supination  may  break  one 
bone  across  the  other,  usually  with  a  spiral  subperiosteal  fracture. 
Subperiosteal  fracture  is  very  apt  to  occur  in  the  bones  of  the 
forearm,  and,  like  greenstick  fracture,  is  likely  to  be  overlooked  or 
neglected,  especially  when  only  one  bone  is  fractured.  Fig.  98  shows 
a  greenstick  fracture  which  was  allowed  to  go  unnoticed  by  the 


292  SURGICAL   DISEASES    OF   CHILDREN 

parents  until  the  weekly  bath  revealed  a  bend  in  the  forearm.  Fig-. 
97  is  from  a  radiograph,  showing  fracture  of  the  radius  and  ulna 
which  was  overlooked  by  an  experienced  surgeon  of  this  city.  The 
child  was  brought  to  me  next  day,  and  perhaps  movement  in  the 
meantime  had  loosened  the  subperiosteal  fissure  sufficiently  so  that 
crepitus  was  detectible.  At  least,  I  so  explained  it  to  the  parents, 
who  were  threatening  trouble  to  the  doctor.  As  is  well  known,  an 
angulated  deformity  of  one  of  the  bones  of  the  forearm  or  a  union 
between  them  may  prevent  pronation  and  supination ;  and  callus 
in  the  interosseous  space  may  do  the  same.  And  as  large  a  cal- 
lus may  be  produced  by  a  fissure  or  a  subperiosteal  fracture  as  by 
a  complete,  or  even  a  compound,  fracture. 

If  the  surgeon  has  any  misgiving,  after  a  careful  examination, 
he  would  better  put  up  the  arm  like  a  fracture  for  at  least  a  week, 
when  the  presence  of  callus  will  confirm  a  well-founded  suspicion. 
If  an  X-ray  apparatus  is  within  reach,  advantage  should  be  taken 
of  its  revelations  in  the  first  instance. 

The  bones  should  be  carefully  straightened  and  paralleled,  and 
a  straight,  flat  splint,  well  padded,  applied  anteriorly  and  posteriorly. 
The  splints  should  be  as  wide  as  or  a  little  wider  than  the  forearm, 
so  that  the  bandage  cannot  press  the  bones  together.  It  is  not  neces- 
sary for  either  splint  to  have  a  longitudinal  ridge  supposed  to  press 
into  the  interosseous  space.    About  three  weeks  is  required  for  union. 

FRACTURE  OR  SEPARATION  OF  OLECRANON 

This  is  not  a  very  common  fracture.  It  is  caused  by  direct 
violence,  together  with  contraction  of  the  triceps.  There  is  distinct 
loss  of  function,  as  the  arm  cannot  be  extended.  Large  effusion  is 
present  in  the  joint.  The  upper  fragment  is  pulled  upward  by  the 
contraction  of  the  triceps,  leaving  a  gap  at  the  back  of  the  elbow. 

The  gap  just  mentioned  should  be  closed  by  extending  the  arm 
and  pressing  down  upon  the  upper  fragment.  It  should  be  held 
down  by  a  strip  of  adhesive  plaster  passed  across  just  above  it. 
This  is  the  only  fracture  or  epiphyseal  separation  which  should  be 
■dressed  with  the  arm  in  complete  extension.  An  anterior  splint  of 
any  material  bandaged  on  maintains  the  position  and  affords  fixa- 
tion. Elevation  on  a  pillow  and  an  icebag  at  the  joint  will  aid  in 
limiting  the  swelling  and  in  reducing  it.  Plenty  of  time  for  firm 
attachment  should  be  given  before  any  attempt  at  flexion  is  made. 
Three  weeks  should  be  sufficient.  Then  the  arm  should  be  gently 
flexed  to  half  way  between  full  extension  and  the  right  angle,  and 
fixed  in  that  position  for  another  week.  After  that  the  angle  should 
be  changed  daily  and  the  arm  massaged  and  brought  into  use.  With 
this  injury  there  is  danger  of  getting  only  fibrous  union.  Even  this 
may  afford  a  useful  arm ;  but  if  the  extremity  is  put  up  as  just 


FRACTURES    AND    SEPARATIONS    OF    EPIPHYSES        293 

described  and  passive  motion  not  attempted  too  soon,  perfect  bony 
union  may  result. 

FRACTURE  OF  SHAFT  OF  FEMUR 

The  shaft  of  the  femur  is  not  infrequently  broken  by  direct  or 
indirect  violence,  and,  it  is  said,  even  from  muscular  action.  This 
latter  must  be  very  rare  indeed. 

The  symptoms  are  obvious,  although  there  may  not  be  much 
pain  or  crepitus,  and  the  treatment  is  simple,  considering  the  size  and 
importance  of  the  bone.  In  the  new-born  infant  the  thighs  may  sim- 
ply be  bandaged  together  with  a  folded  towel  between  knees  and 
ankles  (Owen)  ;  or  straight  splints  of  binder's  board  applied  around 
the  limb  and  retained  by  adhesive  straps  and  a  bandage.  Some  are 
fond  of  the  suspension  treatment  for  broken  thigh.  Buck's  exten- 
sion is  put  on  both  limbs  and  they  are  elevated  perpendicularly,  be- 
ing raised  just  high  enough  to  partly  raise  the  pelvis  from  the  mat- 
tress. The  extending  cord  is  fastened  to  a  cord  or  pole  placed  from 
foot  to  head  of  the  bedstead,  or  to  a  screw  in  the  ceiling.  Weight 
and  pulley  are  not  necessary.  Stimson  tried  an  elastic  cord,  but  dis- 
continued it.  It  is  just  as  well  or  may  be  better,  simply  tied  at  the 
right  elevation.  Excellent  results  are  obtained  in  this  way,  and  a 
child  is  easily  taken  care  of  in  this  position.  Perfect  results  are  also 
obtained  by  simple  straight  splints  from  waist  to  ankle.  Extension 
and  counter-extension  are  unnecessary  in  young  children.  If  a  child 
is  unruly  a  long  side  splint  from  axilla  to  ankle  will  control  him. 
If  suspension  is  used  both  the  fractured  and  the  sound  limb  must 
be  hung  up  and  the  fracture  splinted.  I  have  seen  failure  of  union 
from  suspending  only  the  fractured  one.  Also  in  a  case  in  which 
the  doctor  had  suspended  both  limbs  but  left  the  fracture  unsplinted, 
in  three  weeks  firm  union  had  not  taken  place,  but  a  very  large  callus 
formed.  The  thigh  was  then  fixed  and  in  ten  days  union  was  firm. 
In  female  children  vaginitis  may  occur  during  the  suspension  treat- 
ment, perhaps  from  failure  of  discharges  to  drain  from  that  passage. 

FRACTURES  AND  SEPARATIONS  AT  UPPER  END  OF  FEMUR 

Not  very  numerous  but  decidedly  obscure  injuries  occur  about 
the  upper  end  of  the  femur  in  children.  There  is  no  doubt  that  some 
of  them  are  epiphyseal  separations  and  some  are  fractures  of  the 
neck  or  of  the  base  of  the  neck.  They  are  very  apt  to  produce 
permanent  partial  disability  even  with  the  best  of  treatment ;  and  if 
overlooked  at  the  time  lead  to  subsequent  mistakes  in  diagnosis,  be- 
ing taken  for  congenital  dislocation,  acquired  dislocation,  or  even 
for  paralysis. 

The  symptoms  of  intracapsular  fracture  are  loss  of  function, 
shortening  of  the  limb,  usually  eversion,  elevation  of  the  trochanter, 
pain  and  crepitus.     It  will  be  impossible  in  many  cases  to  ascertain 


294  SURGICAL   DISEASES    OF    CHILDREN 

without  a  resort  to  the  use  of  the  Roentgen  ray,  whether  the  injury 
is  a  fracture  or  an  epiphyseal  separation,  and  whether  the  cleavage 
has  occurred  at  the  head,  neck  or  base  of  the  neck.  Very  forcible 
manipulation  for  the  purpose  of  ascertaining  the  condition  or  eliciting 
crepitus  or  of  correcting  deformity  is  not  to  be  undertaken  without 
due  consideration,  A  greenstick  or  an  impacted  fracture  may  be 
rendered  complete,  or  fragments  separated  or  periosteum  torn 
through  by  injudicious  handling. 

Treatment  is  immobilization  in  as  natural  a  position  as  it  is 
possible  to  attain  without  undue  force.  This  immobilization  should 
be  secured  by  the  method  most  comfortable  for  the  patient  and  most 
convenient  for  preserving  cleanliness.  Full  extension,  traction  to 
make  the  injured  limb  of  equal  length  with  the  sound  one,  slight 
abduction,  which  is  a  more  useful  attitude  in  case  of  ankylosis,  and 
pressure  upon  the  trochanter  sufficient  to  hold  it  in  contact  with  the 
upper  fragment,  are  the  indications  to  be  met.  The  means  best 
adapted  must  be  chosen  to  suit  the  individual  case.  In  infants  and 
bedwetters  it  is  very  difficult  to  keep  the  skin  in  good  condition  under 
fixed  dressings ;  but  by  varnishing  plaster  cases  or  muslin  or  cotton- 
flannel  roller  bandages,  and  the  use  of  oil-silk  or  rubber  sheeting 
properly  placed,  and  by  watchful  care,  it  can  be  done.  A  good  dress- 
ing is  a  plaster  case  from  the  ankle  to  the  chest,  a  reinforcement  of 
a  wooden  slat  or  two  in  front  and  at  the  side  of  the  joint.  Traction 
should  be  kept  on  while  the  plaster  hardens,  and  may  with  advantage 
be  kept  on  until  the  muscles  cease  all  resistance.  A  Liston  long 
side  splint  from  axilla  to  ankle,  with  an  anterior  splint  from  knee 
to  abdomen,  will  answer  the  purpose.  In  a  very  unruly  patient  the 
plaster  or  the  long  splints  can  be  applied  to  both  sides,  and  a  foot- 
piece  across  the  lower  end  prevents  all  twisting.  Buck's  extension, 
as  described  for  hip-joint  disease,  supplemented  with  a  spica  to  fix 
pelvis  and  thigh,  is  convenient  and  efficient.  A  Thomas  hip  splint 
can  be  used  if  obtainable,  or  a  Taylor  hip  splint  as  in  morbus  coxa. 

SEPARATION  OF  TROCHANTER  MAJOR 

This  may  take  place  any  time  between  the  third  and  eighteenth 
year.  It  is  due  to  direct  violence  and  causes  pain,  swelling,  tender- 
ness, with  mobility  of  the  fragment  and  crepitus  if  it  can  be  brought 
in  contact  with  the  point  of  separation  from  the  femur,  as  may  be 
accompHshed  by  abducting  the  limb.  Neither  the  length  of  the  limb 
nor  its  free  passive  mobility  is  altered.  An  unusual  liability  to 
suppuration  accompanies  this  injury,  and  a  number  of  cases  of  fatal 
pyemia  have  been  reported.  The  treatment  is  fixation  with  the  limb 
slightly  abducted  and  rotated  outward.  Any  of  the  methods  de- 
scribed for  fracture  of  the  hip,  omitting  the  traction,  will  serve  for 
this  injury. 


FRACTURES   AND   SEPARATIONS   OF  EPIPHYSES         295 
SEPARATION   OF  LOWER  EPIPHYSIS   OF  FEMUR 

This  is  sometimes  an  obstetric  injury  due  to  traction.  It  may 
occur  during  the  redressement  force  for  genu  valgum,  or  in  efforts 
at  fracturing  the  femur  before  sufficient  use  of  the  osteotome,  or 
by  very  severe  violence,  often  with  twisting  or  wrenching.  In  the 
slighter  cases  there  may  be  little  or  no  displacement,  only  undue 
mobility  and  perhaps  crepitation,  with  pain,  loss  of  function,  and 
later,  swelling.  But  in  the  severe  accidental  cases  there  is  consider- 
able displacement.  It  is  most  usual  for  the  epiphysis  to  be  displaced 
forward  and  the  end  of  the  shaft  backward;  but  this  position  may 
be  reversed.  In  either  forward  or  backward  dispUc:iment  there  is 
great  danger  of  injury  to  the  great  popliteal  vessels  and  nerves. 
Lateral  displacement  may  occur  which  is  less  likely  to  cause  compli- 
cations of  that  kind.  With  displacement  there  may  be  shortening. 
The  margins  of  the  displaced  fragments  can  readily  be  felt,  and  by 
their  position  distinguish  the  injury  from  dislocation  of  the  knee, 
even  without  crepitus.  The  knee  is  generally  slightly  flexed  and  the 
foot  everted. 

With  the  patient  under  anesthesia  the  reduction  presents  no 
great  difficulty.  With  extension  and  counter-extension  the  fragments 
are  manipulated  into  place,  and  the  limb  is  put  up  in  a  fixation 
splint.  This  may  be  of  molded  plaster  or  binder's  board,  well  padded 
to  allow  for  swelling,  especially  in  the  popliteal  region.  The  splint 
should  extend  from  ankle  to  perineum.  To  hang  up  the  splinted 
limb  under  a  cradle  keeps  it  out  of  harm's  way.  In  the  new-born 
union  is  very  prompt,  in  ten  or  twelve  days.  Older  children  require 
a  month.  In  some  cases  the  injuries  to  blood-vessels  or  nerves  form 
very  serious  complications,  which  may  have  to  be  dealt  with.  This 
injury  has  occasionally  ^.ed  to  infective  thrombosis  or  to  gangrene, 
requiring  amputation.  In  the  uncomplicated  cases  the  results  are 
always  satisfactory. 

FRACTURES  OF  SHAFTS  OF  TIBIA  AND  FIBULA 

Not  quite  as  common  as  fracture  of  the  femur,  they  usually 
take  place  in  the  middle  and  lower  thirds.  The  most  common  cause 
is  direct  violence,  and  fracture  of  the  tibia  is  probably  more  likely 
than  any  other  to  be  compound.     (See  Fig.  102.) 

Careful  antisepsis  if  the  fracture  is  compound,  and  accurate 
adjustment  of  the  fragments  are  the  first  steps  in  treatment.  Then 
fixation,  for  which  nothing  is  better  than  plaster  of  Paris.  In  case 
of  a  wound  the  plaster  bandage  is  fenestrated.  The  foot  should 
be  steadied  by  including  it  in  the  plaster,  and  if  the  half-flexed  knee 
also  is  included  it  is  so  much  the  better.  If  no  plaster  is  at  hand, 
binder's  board  or  a  whittled  wooden  splint  may  be  used.  Ready- 
made  splints  seldom  fit. 


296  SURGICAL  DISEASES   OF   CHILDREN 

SEPARATION  OF  TIBIAL  AND  FIBULAR  EPIPHYSES 

The  upper  epiphysis  of  tibia  or  fibula  may  be  separated  by 
violence,  but  the  accident  is  rare.  Separation  of  the  lower  epiphysis 
of  the  tibia  occurs  occasionally  in  the  hands  of  an  accoucheur,  or 
by  accident,  direct  violence,  cross  strain  or  twisting  in  older  children. 
It  is  equivalent  to  Pott's  fracture  in  the  adult,  and  has  the  same 
tendency  to  be  compound.  It  is  sometimes  followed  by  inter- 
ference in  growth  of  the  tibia,  with  overgrowth  of  the  fibula  and 
consequent  inversion  of  the  foot.  Treatment  is  usually  by  a  pos- 
terior or  lateral  molded  plaster  splint,  A  Volkmann  splint  is  ex- 
cellent if  a  small  enough  one  can  be  had. 

THE  PATELLA  AND  TUBERCLE  OF  THE  TIBIA 

The  patella  is  not  broken  in  children;  but  instead  the  tubercle 
of  the  tibia  may  be  torn  off,  and  give  much  the  same  appearance 


Fig.  102.  Radiograph  of  badly  reduced  compound  fracture  of  middle  thikd 
OF  TIBIA  AND  FIBULA.  Admitted  to  St.  Clair  Hospital  four  days  after 
the  accident.  The  ribbon-like  shadow  is  iodoform  gauze  drainage.  The 
fracture  was  then  properly  reduced  and  made  an  excellent  recovery.  Boy 
of  nine  years. 

as  a  fractured  patella.  The  treatment  is  by  full  extension  o£  the 
knee,  and  half  extension  of  the  thigh,  with  cross  strapping  to  hold 
the  patella  down  and  a  posterior  splint  and  a  bandage.  The  union 
should  not  be  trusted  under  five  to  eight  weeks. 

FRACTURES  OF  THE  BONES  OF  THE  FOOT 

These  may  occur  from  direct  or  indirect  violence,  and  unless 
compound  may  be  mistaken  for  strain  or  contusion.  In  case  of 
any  doubt  or  difficulty  anesthesia  should  be  used  in  both  diagnosis 
and  reduction.     With  X-rays  the  injured  and  uninjured  feet  should 


FRACTURES  AND  SEPARATIONS  OF  EPIPHYSES  297 

be  compared.  All  fragments  should  be  reduced  or  if  irreducible 
or  projecting  should  be  removed.  Fragments  of  os  calcis  may  re- 
quire pegging  or  suturing.  No  foot  or  part  of  a  foot  of  a  child 
should  be  sacrificed  without  an  effort  to  save  it  by  strict  antisepsis, 
careful  dressing,  immobilization  and  elevation.  Temporary  dress- 
ings may  be  necessary  for  a  few  days  until  swelling  has  been  re- 
duced, when  firm  fixation  usually  by  plaster  bandage  or  plaster 
splints  is  in  order.  With  an  open  wound  the  fixed  dressing  can  be 
fenestrated.  Children  should  not  be  trusted  on  crutches  too  soon. 
Hot  baths,  massage,  involuntary  and  voluntary  movements  are  use- 
ful measures,  and  come  before  weightbearing. 

METACARPAL  AND  PHALANGEAL  FRACTURES 

These  fractures  are  not  very  common  in  children,  and  when 
they  do  occur  are  apt  to  be  epiphyseal  separations.  They  are  more 
frequent  in  boys  as  a  result  of  baseball  or  football  or  other  rough 
games,  or  in  machinery  accidents.  They  should  receive  very  careful 
attention,  and  even  a  bad  compound  fracture  with  careful  antisepsis 
and  adjustment  of  fragments  and  splinting  may  give  a  good  result. 
No  finger  or  hand  should  ever  be  sacrificed  without  an  effort.  The 
reparative  power  in  the  upper  extremity  of  a  child  is  remarkable. 

FRACTURES  OF  THE  RIBS 

In  children  one  seldom  sees  fracture  of  ribs.  They  are  so 
elastic  they  bend  without  breaking.  When  fracture  does  occur, 
generally  more  than  one  rib  is  broken.  A  blow  or  pressure  that 
will  break  a  child's  ribs  will  generally  do  damage  to  the  contents  of 
the  thorax.  In  fact,  there  may  be  serious  injury  to  thoracic  viscera 
with  no  broken  ribs  and  not  even  a  bruise  externally  to  show  for  it. 
Fracture  may  be  of  the  greenstick  variety,  and  the  deformity  after- 
ward corrected  so  that  upon  examination  nothing  is  found,  or  there 
may  be  perceptible  solution  of  continuity.  Crepitus  may  be  found 
by  palpation,  or  by  ausculation  with  the  stethoscope ;  but  if  not 
found  fracture  is  suspected  if  pain  and  tenderness  be  distinctly  lo- 
calized at  a  point  known  to  have  been  injured.  The  subsequent  ap- 
pearance of  callus  will  confirm  the  diagnosis.  Separation  of  a  rib 
from  its  cartilage  may  also  occur.  Treatment  is  by  cross-strapping 
with  overlapping  strips  of  adhesive,  thus  immobilizing  the  whole  in- 
jured side.     Look  for  hemothorax. 

FRACTURE  OF  STERNUM 

Fracture  of  the  sternum  is  in  the  nature  of  a  diastasis  or  sepa- 
ration of  the  segments  of  bone  which  have  not  yet  become  joined 
by  bony  union.  Fracture  of  sternum  would  be  treated  as  in  the 
adult  by  cross-strapping  with  adhesive  over  the  affected  area,  im- 
mobilizing as  much  as  possible.     Watch  for  hemothorax. 


CHAPTER  XI 

DISLOCATIONS,    CONGENITAL    AND    ACQUIRED 

Abnormal  Laxness  of  Joints — Congenital  Dislocations  of 
THE  Hip,  Knee,  Shoulder  and  Various  Other  Joints — 
Traumatic  Dislocations — Dislocation  of  Radius  and 
Ulna  Backward,  or  Laterally — Dislocation  of  Radius 
AND  Ulna  Forward — Subluxation  of  Radius — Dislocation 
of  the  Radius  Forward  and  Backward — Dislocation  of 
the  Shoulder — Dislocation  of  the  Hip — Dislocation  of 
the  Patella — Dislocations  of  the  Phalanges — Disloca- 
tion OF  the  Thumb — Dislocations  of  the  Sternum  and  of 
the  Ribs — Compound  Dislocations. 

Dislocations  are  congenital  or  acquired.  Acquired  disloca- 
tions are  traumatic  or  spontaneous.  Spontaneous  dislocations  have 
been  discussed  under  arthritis.  The  congenital  dislocations  are  net 
very  unusual  in  children.  They  belong  pathologically  among  the 
malformations,  but  for  convenience  will  receive  some  attention  in 
this  chapter. 

ABNORMAL  LAXNESS  OF  JOINTS 

Children  are  sometimes  brought  for  examination,  under  the 
supposition  that  they  are  "  double  jointed."  Sometimes  only  a  pair 
of  joints  is  affected,  or  one  more  than  all  the  others,  and  it  is  feared 
a  dislocation  has  occurred.  Or  every  joint  in  the  skeleton  may  be 
loosely  put  together.  Upon  examination  neither  traumatism  nor 
actual  malformation  is  found ;  nor  is  the  condition  always  an  evi- 
dence of  rickets ;  but  the  articular  cartilages  are  not  very  well  de- 
veloped and  the  ligaments  are  loose,  allowing  a  great  deal  of  play  in 
the  joint  movements.  Often  the  bones  of  such  children  are  small 
and  the  muscles  delicate.  Some,  however,  are  quite  strong  and 
sinewy  but  present  this  abnormal  laxness  of  the  joints.  Fig.  103 
shows  the  foot  of  an  infant  that  is  not  rickety,  rotated  outward  so 
that  the  toes  almost  point  backward.  Fig.  104  shows  the  elbow 
of  a  boy  at  least  ten  degrees  in  hyper-extension.  These  are  but 
common  examples.  Infants  or  young  children  with  this  unusual 
laxity  may  develop  ordinarily  well-knit  joints.  But  often  the  con- 
dition persists  to  a  degree  throughout  life,  especially  in  women. 

298 


DISLOCATIONS,    CONGENITAL   AND    ACQUIRED 


299 


This   natural   peculiarity  of   conformation   is    sometimes   cultivated 
and  increased  for  exhibition  purposes. 

CONGENITAL  DISLOCATION   OF  THE  HIP 

The  most  important  of  the  congenital  dislocations  is  that  of 
the  hip.  It  is  by  far  the  most  common,  occasions  marked  deformity, 
and  has  received  a  great  deal  of  attention  in  efforts  for  its  relief. 
It  occurs  much  more  frequently  in  females  than  in  males.     Ketch 


Fig.  103. 


Illustrating  laxness  of  joints  not  uncommon  in  infancy  and 
childhood. 


and  Hubbard,  in  Keating's  Cyclopedia,  place  the  proportion  at  3^ 
to  I.  Many  writers  state  it  to  be  more  often  bilateral  than  unilateral, 
but  the  authors  just  quoted  in  an  analysis  of  55  cases  found  both 
joints  affected  in  20  and  only  one  in  35  instances;  and  in  the  uni- 
lateral cases  the  left  side  was  affected  five  times  as  often  as  the 
right. 

Numerous  theories  as  to  causation  have  been  advanced,  but 
none  of  them  are  satisfactory.  Formerly  many  of  the  cases  were 
attributed  to  obstetric  manipulations,  producing  a  dislocation  which 
was  undiscovered  at  the  time.  But  while  traumatic  dislocation  at 
birth  is  a  possibility,  as  is  also  epiphyseal  separation,  both  of  these 
are  quite  different  from  that  condition  which  is  called  congenital 
dislocation,  and  should  not  be  confused  with  it.  The  theories  of 
the  origin  do  not  after  all  explain.  They  are,  ultimately,  only  con- 
fessions of  ignorance.  When  we  say  that  there  is  some  "  alteration 
of  the  primitive  germ,"  or  "  a  change  in  the  nerve  centers  which 
leads  to  perverted  development,"  the  etiology  has  reached  its  limit 
for  the  present. 


300  SURGICAL   DISEASES    OF   CHILDREN 

After  much  controversy  it  is  generally  conceded  that  mal- 
formation of  the  acetabulum,  particularly  of  its  iliac  portion,  is 
present,  although  the  degree  of  this  malformation  varies;  and  that 
the  head  of  the  femur  is  stunted  and  misshapen,  being,  however, 
often  too  large  for  the  acetabulum.  The  acetabulum  may  be  a  mere 
depression  or  it  may  have  an  abortive  ridge  of  bone  for  a  rim ;  or 
in  the  new  situation  of  the  femoral  head  upon  the  dorsum  ilii  there 
may  have  been  an  attempt  at  the  formation  of  a  new  acetabulum. 


Fig.    104.     Illustrating   abnormal   laxness   of  joints   in   many  children. 
Hyperextension   of  elbow,  boy  ten  years   old. 

The  capsule  of  the  joint  usually  retains  its  attachment  to  femur  and 
pelvis,  being  stretched  sufficiently  to  allow  the  dislocation ;  or  the 
head  may  have  escaped  through  an  opening  in  the  capsule  and  have 
a  new  fibrous  investment  resembling  a  capsule,  and  this  may  or 
may  not  be  lined  with  synovial  membrane  at  the  location  of  the  new 
rudimentary  acetabulum.  The  usual  displacement  is  upward  and 
backward  upon  the  dorsum  ilii,  but  it  may  be  in  other  positions. 
The  condition  varies  much  in  different  cases,  and  also  changes  take 
place  as  the  patient  gets  older.  Often  the  shallow  acetabulum  is 
filled  up  with  a  fatty  cushion,  the  ligamentum  teres  is  attenuated, 
the  muscles  atrophic,  the  fascise  and  capsular  structures  contracted, 
excepting  as  weight-bearing  has  stretched  them  and  thrust  the 
femoral  head  still  farther  above  its  normal  location.  The  condi- 
tion is  often  not  discovered  until  the  child  learns  to  walk. 

Symptoms. — The  most  obvious  symptom  is  the  rolling  gait, 
which  is  most  marked  if  the  trouble  is  bilateral.  At  each  step  the 
body  is  swung  outward  over  the  limb  that  is  put  forward,  which 
causes  a  remarkable  waddling  or  swaying  in  the  walk,  while  the 
heels  scarcely  touch  the  ground.  The  hips  appear  wide,  with  a  space 
between  the  thighs  or  broadening  of  the  perineum.  The  buttocks 
project  outward  and  backward,  with  the  great  trochanters  above 
Nelaton's  line.  The  femoral  heads  being  behind  the  acetabula, 
the  pelvis  is  tilted  forward,  that  is,  with  the  pubis  lowered;  conse- 
quently, to  maintain  the  shoulders  upright  the  lumbar  spine  is  curved 
into  lordosis.     (See  Figs.  105,  106,  107,  108.)     If  the  dislocation 


DISLOCATIONS,    CONGENITAL  AND   ACQUIRED 


301 


is  unilateral  the  gait  and  appearances  are  modified  according'ly. 
The  afifected  limb  being  shorter  than  the  sound  one,  a  limp  is  added, 
and  to  the  lordosis  a  lateral  curvature.  In  bilateral  cases  the  short- 
ening of  the  limbs  is  usually  about  the  same  on  both  sides,  and 
there  is  no  limp,  but  more  swaying.  With  the  child  lying  down  it 
can  be  readily  demonstrated  that  the  joint  is  freely  movable,  ex- 
cepting perhaps  in  the  extreme  range  of  adduction  and  outward 


Fig.  105.  Congenital  disloca- 
tion, BOTH  HIPS.  Front 
view.    Same  case  as  Fig.  106. 


Fig.  106.  Congenital  disloca- 
tion, BOTH  HIPS.  Side  view. 
Same  case   as   Fig.    105. 


rotation,  and  that  the  affected  limb  or  limbs  can  be  lengthened  a 
half  inch  to  two  inches  by  pulling;  but  the  original  position  is  im- 
mediately resumed  on  relaxing  the  traction,  thus  moving  down  and 
up  on  the  ilium,  with  a  slight  "  knocking  "  as  it  does  so. 

Diagnosis. — The  diagnosis  should  present  no  difficulty,  espe- 
cially if  one  has  the  history. 


302 


SURGICAL  DISEASES    OF  CHILDREN 


Prognosis. — The  prognosis  is  not  favorable  for  improvement 
with  age  and  use.  Nor  can  one  be  sanguine  of  permanent  cure 
with  any  plan  of  treatment  yet  devised.     With  a  favorable  case  there 


Fig.  107-A.  Congenital  dis- 
location, ONE  hip.  Side 
view.     Same  case   as   107-B. 


Fig.  IG7-B.  Congenital  disloca- 
tion. Back  view,  same  case. 
Girl  8  vears   old. 


is  a  fair  prospect  of  great  improvement  and  possibly  cure  after 
operation. 

Treatment. — There  are  not  many  topics  connected  with  pediat- 
rics, surgery  or  orthopedics  which  have  been  more  discussed  by  the 
profession  (and  the  public  too)  in  the  last  few  years  than  this  one. 
The  literature  is  voluminous  and  still  augmenting.  To  trace  the 
history  of  the  controversy  is  outside  the  scope  of  this  work.  The 
question  is  not  yet  settled  to  the  satisfaction  of  the  majority  of 


DISLOCATIONS,    CONGENITAL    AND    ACQUIRED  303 

professional  minds.  Nor  shall  I  attempt  to  present  the  variations 
and  modifications  of  the  different  operations  and  methods  of  treat- 
ment. 

There  are  those  who  follow  an  alto^2:ether  expectant  plan  in 
these  cases.  And  there  are  cases  of  so  mild  a  grade,  afifecting  both 
sides  alike  and  causing  so  little  deformity,  that  they  are  best  left 
alone.  If  there  is  only  slight  shortening  in  one  limb  a  slightly 
thicker  sole  upon  the  shoe  may  supply  the  difference  and  correct 
the  limp,  so  that  with  a  little  management  of  the  clothing  the  de- 
formity gives  no  trouble  and  passes  unnoticed. 

Another  method  endeavors  to  hold  down  the  trochanters  by  a 
wide  firm  band  or  corset  held  down  upon  them  by  perineal  bands 
which  take  their  bearing  upon  the  tuber  ischii.  Numerous  cases 
treated  in  this  way  are  prevented  from  growing  worse  and  get  along 
with  little  show  of  deformity  while  they  wear  the  apparatus. 

Still  other  plans  employ  traction.  It  may  be  applied  by  ambula- 
tory braces  similar  to  the  traction  splints  used  for  morbus  coxae,  or 
a  combination  of  this  with  the  trochanteric  corset  just  described; 
or  traction  by  weight  and  pulley  with  the  patient  confined  to  the 
horizontal  position  for  years,  gradually  bringing  down  the  head  of 
the  femur  to  the  acetabulum  and  then  holding  it  there  until  it  will 
stay  there  without  the  traction  or  any  apparatus,  or  with  the  aid  of 
apparatus ;  and  then  bringing  it  into  use  by  passive  motion.  A  num- 
ber of  cases  treated  by  this  mild,  patient  and  painstaking  method  have 
been  reported  cured ;  but  as  Bradford  has  shown,  after  a  few  years 
more  they  are  in  much  the  same  condition  as  when  the  treatment 
was  begun.  About  the  same  report  can  be  made  of  various  postural 
methods — they  cure  temporarily,  but  relapse  follows. 

The  methods  remaining  to  be  mentioned  are  either  cutting 
operations  or  the  so-called  bloodless  method.  Operations  consist 
of  tenotomies  of  the  shortened  tendons  that  interfere  with  traction  or 
postural  methods ;  or  of  division  of  the  muscles  about  the  joint  so 
as  to  allow  of  its  reduction ;  or  this  with  opening  the  capsule  and  re- 
placing the  head  of  the  femur  in  the  acetabulum,  sometimes  also 
cutting  deeper  the  acetabulum  to  receive  the  head ;  or  resection  of 
the  articular  extremity  of  the  femur.  These  operations  all  have 
many  variations  and  modifications. 

Hoffa's  Operation. — The  operation  that  is  perhaps  most  com- 
mended by  those  who  advise  any  open  operation  at  all,  is  that  which 
bears  the  name  of  Hoffa,  and  it  has  modifications  too  numerous  to 
describe.  Some  advise  preliminary  traction,  for  some  days  previous 
to  the  operation,  with  weight  and  pulley  or  other  apparatus.  This 
brings  the  head  of  the  femur  down  from  its  position  on  the  dorsum 
ilii  to  a  point  below  the  iliac  crest.  If  necessary  the  adductor  ten- 
dons are  divided  close  to  their  pubic  attachment.     Arrangements 


304  SURGICAL   DISEASES    OF    CHILDREN 

are  made  for  extension  and  counter-extension  during  the  operation. 
A  strong  and  thick  perineal  band  covered  with  a  wetted  antiseptic 
towel  is  connected  with  a  ring  in  the  floor  or  wall  of  the  room  for 
counter-extension.  And  a  similar  band,  which  may  be  a  long  towel, 
a  rolled  sheet  or  the  like,  should  be  fastened  with  a  clove  hitch  to 
the  thigh  for  making  extension.  Then  after  complete  antiseptic 
preparation  an  incision  is  made  beginning  just  below  the  anterior 
superior  iliac  spine  and  extending  downward  and  backward  along 
the  outer  margin  of  the  tensor  vaginae  femoris.  Dissection  is  car- 
ried between  that  muscle  and  the  gluteus  medius,  down  to  the  cap- 
sule. The  wound  being  retracted,  the  capsule  is  incised  and  the 
head  and  neck  exposed.  The  attachments  of  the  capsule  around  the 
neck  of  the  femur  are  divided.  Any  constriction,  "  hour-glass  " 
contraction,  or  adhesion  about  the  capsule  which  would  prevent 
the  reduction  is  cut,  or  stretched  by  a  dilator,  but  the  anterior  part 
of  the  capsule  and  the  ilio-psoas  tendon  are  spared.  The  ligamentum 
teres  may  be  cut  if  it  interferes  with  the  inspection  of  the  joint. 
The  extension  being  released,  the  acetabulum  is  examined,  and  if 
it  is  to  be  deepened  this  is  done  with  a  large  curette.  The  femur  is 
now  pulled  down  and  placed  in  the  socket.  This  may  be  accom,- 
pHshed  by  maneuvers,  or  the  limb  may  have  to  be  abducted  and 
traction  made,  and  when  the  head  is  opposite  the  cavity,  lateral  push- 
ing upon  the  trochanter  puts  it  into  place.  In  some  cases  the  bone 
is  twisted  forward  so  that  strong  inversion  is  necessary  to  point  th^ 
head  into  the  cavity.  An  essential  point  is  that  no  portion  of  the 
capsule  shall  be  folded  in  between  head  and  acetabulum.  The  re- 
duction should  be  so  complete  that  when  the  limb  is  extended  it  stays 
in  place.  The  incision  in  the  capsule  is  now  closed  so  far  as  possible 
with  catgut  sutures.  Some  surgeons  drain  the  joint,  and  others  only 
drain  down  to  the  capsule  with  a  small  dram.  The  deep  and  super- 
ficial fasciae  and  the  skin  are  sutured.  After  the  antiseptic  dressing 
with  the  thigh  strongly  abducted,  the  whole  limb  from  the  foot  up 
is  put  up  in  a  plaster  spica  and  this  extended  to  the  thorax.  Some 
make  it  a  double  spica  including  the  other  limb  also,  even  in  one- 
sided cases.  In  three  months  or  more  the  spica  is  removed  and  an- 
other put  on  after  straightening  the  limb  somewhat.  In  one-sided 
cases  the  sound  limb  is  not  included  in  the  plaster  this  time.  At  a 
subsequent  dressing  the  knee  and  leg  are  left  free,  and  with  crutches 
the  child  may  go  about  carrying  the  thigh  in  the  plaster  spica  still  in 
wide  abduction.  In  nine  months  to  a  year  or  more  the  cast  is  left 
off.  If  the  inversion  persists,  a  subtrochanteric  osteotomy  may  be 
done. 

Bloodless  Reduction. — Although  this  method  of  treatment  was 
not  originated  by  Lorenz,  he  systematized  and  elaborated  and  advo- 
cated it  until  it  is  usually  spoken  of  as  the  Lorenz  method.     The 


DISLOCATIONS,    CONGENITAL   AND    ACQUIRED  305 

preparatory  treatment  not  invariably  used  is  moderate  traction  in 
the  position  of  abdviction,  which  is  kept  up  for  several  days.  Then 
under  anesthesia  powerful  traction  is  made  downward  in  abduction. 
This  may  be  effected  by  counter-extension  bands  around  the  thigh 
and  across  the  perineum  (not  pressing  upon  the  genitals)  fastened 
to  a  stationary  table  or  a  ring  in  the  wall  of  the  room,  while  the  ex- 
tension is  made  manually  or  with  block  and  tackle  attached  to  bands 
upon  thigh  and  leg.  Or  the  limb  may  be  placed  in  a  traction  appa- 
ratus such  as  that  devised  by  Bradford  at  the  Boston  Children's 
Hospital,  which  consists  essentially  of  a  very  strong  Thomas  knee 
splint  well  padded  at  the  upper  end  for  the  counter-traction,  and 
having  a  windlass  at  the  lower  end  for  the  traction.  The  limb  is 
pulled  down  until  the  trochanter  is  at  Nekton's  line  when  the  limb 
is  straightened.  The  thigh  is  then  flexed  straight  forward  to  a 
right  angle,  rotated  inward,  and  then  abducted  to  almost  a  right 
angle.  If  the  maneuvers  are  successful  the  head  should  pass  over 
the  margin  of  the  acetabulum  and  into  its  socket  with  a  distinct 
impact,  and  it  should  stay  there  when  the  limb  is  brought  down 
straight.  If  it  does  not,  but  slips  out  again,  more  stretching  is  nec- 
essary. Sometimes  at  this  point  tenotomy  of  the  adductors  is  re- 
quired. When  certain  that  reduction  has  been  effected  the  thigh 
is  held  in  extreme  abduction  and  flexion  at  a  right  angle,  while  a 
plaster  spica  is  applied  to  limb  and  pelvis  and  up  to  the  thorax.  The 
child  is  soon  allowed  to  go  about  with  crutches,  carrying  the  plaster. 
It  is  kept  in  this  position  six  to  eight  months,  the  casts  being  renewed 
when  necessary,  then  gradually  straightened.  As  after  the  open 
operation,  if  great  inversion  persists,  subtrochanteric  osteotomy  must 
de  done. 

Among  the  many  methods,  modifications  and  apparatuses  that 
have  been  presented  to  the  profession,  one  of  the  most  recent  is  that 
of  Hibbs,  of  New  York.^ 

He  has  devised  an  apparatus  which  consists  of  a  board  two 
inches  thick,  six  feet  long  and  two  feet  wide,  with  two  windlass  pul- 
leys on  the  under  surface.  This  is  shown  in  Figs.  108  and  109,  and 
with  the  operation,  described  substantially  as  follows: 

In  this  board  or  table-top,  the  two  larger  openings,  A  and  B 
(Fig.  108),  are  made  for  the  trochanteric  pad.  At  C  and  D  are  at- 
tachments for  the  pelvic  straps,  and  at  E  is  a  roller  over  which  the 
straps  run.  The  child  is  placed  on  the  solid  board  between  the  two 
openings,  A  and  B.  The  two  padded  pelvic  straps  are  attached  at 
C  and  D,  which  are  widely  enough  separated  for  the  straps  to  pass 
just  internal  to  the  crest  of  the  ilium,  down  over  the  ramus  of  the 
pubis  running  over  the  roller  just  in  front  of  the  perineum  at  E  to 
the  under  surface  of  the  board,  where  they  are  attached  to  the  two 
1  N.  Y.    Med.  Jour.,  Apr.  25,  1908. 


3o6 


SURGICAL  DISEASES    OF   CHILDREN 


windlass  pulleys.  By  means  of  the  windlass  sufficient  pressure  may 
be  made  on  these  straps  to  hold  the  pelvis  immovably,  without  the 
slightest  damage  to  the  skin  or  any  other  part.    The  holding  force 


Fig.   io8.    Hiebs'  apparatus  for  reducing  congenital  dislocation  of  hips 

as   seen  from  above. 

is  exerted  laterally  against  the  sides  of  the  pelvis  as  well  as  back- 
ward. The  trochanteric  pad  is  5  inches  by  i-|  inches  in  size,  and 
hollow.  It  is  made  of  highly  polished  steel,  as  such  a  surface  slides 
over  the  skin  with  the  least  possible  friction.    The  pad  is  attached  to 


Fig.   109.  HiBBs'  apparatus  for  reducing  congenital  dislocation  of  hips. 

Side  view. 

the  under  surface  of  the  table,  and  by  means  of  a  wormscrew  miech- 
anism  it  can  be  forced  up  through  either  opening  A.  or  B.  against 
either  the  right  or  left  trochanter  and  fastened  at  any  point,  im- 
movably. The  steps  of  the  operation  are  shown  in  Figs,  no,  in 
and  112.  First,  the  child  is  placed  upon  the  table  and  the  pelvic 
straps  attached,  then  the  leg  to  be  operated  on  is  flexed  on  the  ab- 


DISLOCATIONS,    CONGENITAL   AND    ACQUIRED  307 

domen.  The  pelvis  is  made  immovable  by  tightening  the  straps  with 
the  windlass.  Secondly,  the  leg  is  extended  on  the  thigh  with  the 
thigh  held  in  adduction  and  flexion  on  the  abdomen,  thus  forcing 
the  head  below  the  acetabulum.  At  this  point  the  operator,  by  means 
of  the  wheel  and  worm  screw  mechanism,  forces  the  trochanteric 
pad  upward  and  forward  through  the  opening  in  the  board  against 
the  trochanter,  where  it  is  lixed  immovably.  The  thigh  is  then  ex- 
tended and  abducted,  forcing  the  head  to  travel  upward  anteriorly 


First  step  of  operation. 


into  the  acetabulum.  The  degree  of  extension  of  the  thigh  necessary 
before  the  head  reaches  the  acetabulum  in  its  course  upward  will 
depend  upon  the  distance  below  the  acetabulum  at  which  it  rests 
when  the  thigh  is  in  flexion  and  adduction  on  the  abdomen  and  the 
leg  extended,  and  will  be  less  in  the  older  cases.  The  lower  the  head 
is  gotten,  the  easier  will  be  the  reduction,  as  when  it  is  well  below 
the  acetabulum,  it  is  forced  into  the  anterior  route  more  gradually. 
The  reduction  is  accomplished  often  with  an  audible  snap,  and  the 
sensation  to  the  hands  of  the  operator  can  hardly  be  mistaken.  The 
muscles  become  taut  and  the  leg  is  flexed. 

Thirdly,  the  plaster  is  applied  with  the  thigh  in  abduction  and 
flexion,  so  as  to  put  considerable  tension  on  the  muscles,  and  the 
knee  is  included  in  the  plaster  with  the  leg  extended  so  that  the 
ham  strings  are  tense.  (See  Figs.  113  and  114.)  The  angles  of  ab- 
duction and  flexion  will  vary  with  the  age  of  the  patient,  being 
greater  in  those  with  most  shortening.  However,  in  some  cases  the 
leg  is  brought  to  a  position  of  10  degrees  abduction  and  80  degrees 
extension  in  the  first  plaster,  as  seen  in  Fig.  115.  The  first  plaster 
should  be  changed  at  the  end  of  two  weeks,  when  it  will  be  found 


3o8 


SURGICAL   DISEASES    OF   CHILDREN 


possible  to  place  the  limb  nearer  the  normal  position,  and  the  plaster 
should  be  changed  every  two  weeks  until  its  removal.     Dr.  Hibbs 

doubts  the  necessity  of  any  case 
wearing  plaster  more  than  two 
months,  and  at  the  most  three 
months.  In  many  a  shorter  time 
is  sufficient. 

With  this  apparatus  fourteen 
hips  have  been  reduced  in  thir- 
teen children,  varying  in  age 
from  twenty-one  months  to 
eleven  years,  and  no  evident 
traum.atism  has  been  produced. 
It  seems  reasonable  to  expect 
if  the  acetabulum  is  large 
enough  to  receive  the  head  and 
both  are  fairly  developed  that 
the  result  should  be  stable,  from 
the  fact  that  the  integrity  of 
muscles  and  structures  about 
the  joint  remains  unimpaired 
by  the  operation. 
Ridlon  of  Chicago  uses  a  method  of  manipulation  that  is  a  little 
different  from  that  of  any  of  the  other  surgeons  that  I  know  about. 


Fig.  III.     Second  step  of  operation. 


Fig.    112.     Third   step  of  operation. 

He  does  no  preliminary  stretching  of  any  kind,  neither  by  weight 
and  pulley  traction  in  bed  before  the  day  of  the  operation,  nor  by 


DISLOCATIONS,  CONGENITAL  AND   ACQUIRED  309 

hand  or  any  mechanical  device  to  pull  the  limb  outwards  at  the  time 
of  the  operation,  nor  to  stretch  the  capsule  as  Lorenz  did  by  extreme 
flexion  of  the  limb  with  the  knee  straight  and  by  extreme  hyperex- 
tension.     He  has  not  used  the  Koenig  block  which  used  to  be  em- 


FiG.    113.     Congenital  dislocation   of   hip.   after   reduction.     First   plaster, 
showing  degree  of  abduction.     Case  of  Dr.  R.  A.  Hibbs. 

ployed  by  Lorenz  for  more  than  four  years.  But  in  extremely  diffi- 
cult cases  he  rests  the  patient's  pelvis  on  a  sandbag  some  three  inches 
thick  in  order  to  get  a  better  leverage  for  the  manipulation.  The 
manipulation  is  as  follows :     With  the  pelvis  on  the  opposite  side 


F17   114.     Congenital  dislocation   of  hip   after   reduction,   put   up   in   first 
plaster  showing  degree  of  flexion.     Case   of  Dr.    R.   A.    Hibbs. 

held  down  by  an  assistant  he  fully  flexes  the  thigh  on  the  side  of  the 
dislocated  hip,  the  knee  also  being  flexed.  Then  with  one  hand  on 
the  knee  pushing  the  head  of  the  femur  downwards  and  with  the 
fingers  of  the  other  hand  beneath  the  greater  trochanter,  neck  and 
head  of  the  femur  so  that  the  direction  of  the  head  in  relation  to  the 


310 


SURGICAL   DISEASES    OF   CHILDREN 


greater  trochanter  can  be  felt,  the  thigh  is  rotated  inwards  by  turn- 
ing the  foot  and  leg  outwards,  thus  throwing  the  head  a  little  lower 
down  and  in  the  direction  of  the  lower  and  posterior  border  of  the 

acetabulum.  In  this  position  the  thigh 
is  abducted  with  the  hand  on  the  knee, 
the  head  and  neck  of  the  femur  are 
lifted  upwards  (forwards)  with  the 
fingers  that  are  underneath  it,  the  thumb 
being  in  place  on  the  groin  until  the 
head  passes  into  the  acetabulum.  The 
head  is  then  pressed  into  the  acetabu- 
lum, and  at  the  same  time  the  thigh  is 
rotated  with  the  hand  on  the  knee. 
Ridlon  claims  that  by  this  manipulation 
it  is  possible  in  almost  all  cases  to  effect 
a  reduction  without  tearing  or  greatly 
stretching  the  adductor  muscles,  as  oc- 
curs in  the  Lorenz  handling,  and  there 
can  be  no  doubt  that  the  less  tearing 
and  stretching  that  occurs  in  the  mus- 
cles surrounding  the  joint  the  more  se- 
curely will  the  replaced  hip  be  held. 
He  then  tests  what  position  seems  most 
secure,  and  usually  finds  it  to  be  the 
Lorenz  position,  Avhich  has  been  called 
the  position  of  right-angled  abduction, 
but  it  also  includes  outward  rotation  of 
the  thigh  to  about  90  degrees,  so  that 
when  the  child  lies  on  its  back  the  outer 
side  of  the  foot  and  the  leg  lies  on  the 
same  plane  as  the  back,  resting  upon 
the  table  or  bed.  But  occasionally  the 
Lange  position  is  found  to  be  the  more 
secure  one.  This  is  right-angled  ab- 
duction without  outward  rotation,  so 
that  when  the  child  lies  on  its  back  on 
the  "table  the  back  of  the  thigh  muscles 
rest  on  the  table  and  the  leg  below  the  knee  hangs  directly  down- 
wards at  the  side  of  the  table.  Obviously  this  is  a  difficult  position, 
both  while  the  child  lies  in  bed  and  after  he  gets  up  to  walk.  Rid- 
lon does  not,  when  using  the  Lange  position,  carry  the  plaster  splint 
below  the  knee,  as  many  surgeons  have  done,  in  order  to  retain  the 
limb  absolutely  in  this  position  and  prevent  the  thigh  from  rotating. 
He  has  observed  that  so  long  as  the  child  lies  in  bed  with  the  leg 
below  the  knee  hau'^ing  over  the  side  of  the  bed  and  downwards 


Fig.  115.  After  reduc- 
tion OF  CONGENITALLY  DIS- 
LOCATED HIP.  Limb  put  up 
in  first  plaster  with  10  de- 
grees abduction  and  180  de- 
grees extension.  Girl  il 
years  old.   Dr.  R.  A.  Hibbs. 


DISLOCATIONS,   CONGENITAL   AND   ACQUIRED  31I 

towards  the  floor,  that  the  original  position  in  regard  to  absence  of 
rotation  is  maintained ;  but  that  as  soon  as  the  child  is  let  up  and 
allowed  to  walk  the  thigh  gradually  rotates  into  practically  the  same 
position  that  it  has  when  the  limb  has  been  put  up  in  the  typical 
Lorenz  position.  In  other  words,  the  thigh  gradually  rotates  out- 
wards from  the  position  of  no  rotation  when  the  Lange  position  is 
employed,  as  it  rotates  inward  somewhat  from  90  degrees  of  out- 
ward rotation  of  the  original  Lorenz  position  when  the  child  begins 
to  walko 

The  dangers  of  laceration  of  muscles,  rupture  of  vessels,  frac- 
ture of  bones  or  separation  of  epiphyses,  injury  of  nerves,  contusions, 
with  resultant  hemorrhages,  paralyses,  contractions  or  sometimes 
gangrene,  which  are  associated  with  the  "  bloodless  "  method,  are 
not  to  be  ignored ;  nor  is  the  fact  that  relapses  frequently  occur. 
With  the  open  method  the  great  danger  connected  with  the  opera- 
tion is  sepsis,  which  may  of  course  prove  fatal ;  or  in  the  way  of  an 
unfavorable  result,  ankylosis.  It  is  to  be  hoped  and  expected  that 
further  study  will  fix  the  indications,  set  the  limitations,  and  perfect 
the  technique  of  all  these  procedures  so  that  a  safe  and  satisfactory 
line  of  treatment  can  be  laid  down. 

The  open  operation  is  used  in  the  older  cases,  some  say  in  chil- 
dren from  four  to  ten  years ;  others  place  it  at  seven  to  ten  or  more 
years ;  but  all  agree  that  after  puberty  the  prognosis  is  poor,  and  the 
choice  then  lies  between  excision  if  the  joint  is  painful  or  trouble- 
some, and  the  corset  for  holding  down  the  trochanters.  The  age 
limit  for  the  bloodless  reduction  is  seven  years  for  the  unilateral 
cases,  and  four  or  five  years  for  the  bilateral  cases.  It  is  sometimes 
said  that  the  bloodless  reduction  should  be  tried  first,  and  if  it  does 
not  succeed,  arthrotomy  should  be  resorted  to;  but  it  may  occur 
that  the  effort  at  reduction  and  its  results  have  so  changed  the  con- 
ditions that  reduction  by  arthrotomy  is  impossible. 

CONGENITAL  DISLOCATION  OF  THE  KNEE 

This  is  much  more  rare  than  congenital  dislocation  of  the  hip. 

Fig.  116  shows  the  lower  extremity  of  a  babe  in  which  the  knee 
could  be  hyperextended  about  forty-five  degrees.  Such  cases  are 
sometimes  called  congenital  dislocation  of  the  knee.  But  the  joint 
is  not  entirely  dislocated,  or  is  only  a  mild  grade  of  deformity.  It 
is  readily  brought  into  normal  position  either  by  passive  or  active 
motion.  A  knee  held  continuously  in  that  position  by  congenital 
deformity  with  contracted  tendons  is  called  genu-recurvatum,  and 
is  similar  in  its  origin  to  talipes  calcaneus,  which  sometimes  accom- 
panies it. 

Hyperextension  of  the  knee  in  some  cases  does  amount  to  a 
dislocation,  and  this  is  the  more  common  of  the  two  principal  forms. 


312  SURGICAL   DISEASES    OF   CHILDkEN 

It  may  extend  to  or  beyond  the  right  angle,  or  so  that  the  toes  are 
near  the  groin.  The  articular  surface  of  the  tibia  in  these  cases  lies 
upon  the  anterior  edges  of  the  condyles.  The  patella  may  be  small 
or  absent.     In  the  other  principal  form  the  tibia  is  luxated  or  sub- 


FiG.    ii6.     Hyperextension   of  the  knee.     Genu-recurvatum. 


luxated  backward.  Lateral  displacements  are  extremely  uncommon, 
yet  such  have  been  reported.  Most  cases  are  readily  reduced,  al- 
though ankylosis  has  been  known  to  accompany  the  condition. 

Treatment  is  reduction  and  the  use  of  a  splint  of  suitable  form 
to  prevent  its  recurrence,  but  to  allow  normal  motion.  An  anterior 
splint  attached  by  encircling  bands  only  to  the  leg  or  only  to  the 
thigh,  but  extending  also  upon  the  articulating  bone,  will  answer 
the  purpose. 

CONGENITAL  DISLOCATION  OF  THE  SHOULDER 

Many  of  the  cases  which  have  been  described  under  this  heading 
prove  upon  examination  to  have  been  the  results  either  of  injury  at 
birth,  with  or  without  resulting  paralysis,  or  of  paralysis  alone.  Yet 
cases  of  undoubted  congenital  dislocation  do  occur,  though  they  are 
extremely  rare. 

Figs.  117  and  118  are  from  photographs  of  a  case  in  my  own 
practice.  It  occurred  in  association  with  a  congenitally  dislocated 
hip.     The  infant  died  when  eight  months  old  of  acute  intestinal  in- 


DISLOCATIONS,   CONGENITAL  AND   ACQUIRED  313 

fection,  and  I  was  able  to  secure  only  the  shoulder  joint.  It  shows 
imperfect  development  of  the  glenoid  cavity  and  also  of  the  head  of 
the  humerus,   which   rested   in,   or   rather   upon,   the   rudimentary 


Fig.    117.     B   shows   a   specimen   of   congenital    dislocation   of  the   shoulder. 
A   is   a   normal   joint   for   comparison. 


Fig  118.     Same  case  as  above,  with  joints  laid  open.     B,  congenital  disloca- 
tion of  shoulder.     A,  normal  joint  for  comparison. 

cavity,  but  low  with  reference  to  the  acromion,  and  projected  back- 
ward. 

Treatment. — Treatment  of  congenital  dislocation  of  the  shoulder 


314  SURGICAL   DISEASES    OF   CHILDREN 

has  thus  far  proven  very  unsatisfactory  or  a  total  failure.     None  of 
the  published  results  can  fairly  claim  anything  more. 

CONGENITAL  DISLOCATION  OF  VARIOUS  OTHER  JOINTS 

Congenital  dislocations  of  the  elbow  and  wrist  joints,  the  tem- 
poro-maxillary,  occipito-atlantoid,  of  the  ankle,  of  the  phalangeal,  in 
fact,  of  almost  any  joint,  are  occasionally  reported ;  but  possess  no 
surgical  interest.  They  are  usually  capable  of  being  reduced,  so  far 
as  the  formation  of  the  joint  allows  reduction  in  its  usual  sense,  and 
retained  by  some  form  of  apparatus ;  or  in  some  situations  resection 
or  arthrodesis  might  be. preferable. 

TRAUMATIC  DISLOCATIONS 

Traumatic  dislocations  are  less  common  in  children  in  compari- 
son with  adults,  apparently  for  two  reasons,  the  elasticity  and  free- 
dom of  movement  in  the  joints,  and  the  yielding  of  the  epiphyseal 
junctions  in  case  of  violence. 

DISLOCATION    OF    RADIUS    AND    ULNA    BACKWARD,    OR 

LATERALLY 

Dislocations  of  one  kind  or  another  at  the  elbow  joint  are  the 
most  frequent  of  all  the  dislocations  in  children,  and  are  not  un- 
common. With  any  of  them  there  is  apt  to  be  also  separation  of  an 
epiphysis  or  a  fracture.  Dislocation  is  either  backward  or  forward, 
or  it  may  be  backward  and  laterally,  or  only  laterally,  either  toward 
the  inside  or  outside,  often  accompanied  with  a  fracture  or  epiphy- 
seal separation  of  one  or  the  other  cond3de.  (See  Figs.  119  and 
120.) 

When  the  radius  and  ulna  are  displaced  backward  the  coronoid 
process  of  the  ulna  is  likely  to  be  detached.  (Owen.)  It  is  most 
commonly  caused  by  a  fall,  but  it  is  not  always  possible  to  say  ex- 
actly in  just  what  direction  the  force  was  applied.  I  once  had  a  case 
of  backward  displacement  of  both  forearms  produced  simultaneously 
in  an  overgrown  boy  by  a  fall  from  an  old-fashioned  high  veloci- 
pede. The  boy  said  he  pitched  over  the  handle-bars  and  struck  on 
his  hands  with  arms  outstretched. 

Symptoms  and  Diagnosis. — The  symptoms  of  dislocation  back- 
ward are  a  shortening  of  the  forearm  on  its  anterior  aspect,  with 
projection  of  the  olecranon  beyond  the  line  of  the  humerus  at  the 
back  of  the  elbow.  The  arm  is  held  half  way  between  full  extension 
and  flexion  to  the  right  angle,  and  is  more  or  less  rigid  in  that  posi- 
tion, unless  the  injury  is  complicated  with  fracture  above  the  con- 
dyles or  epiphyseal  separation.  On  examining  the  relative  position 
of  the  epicondyles  and  tip  of  the  olecranon  (as  described  under  In- 
juries of  the  Humerus  Near  the  Elbow),  it  will  be  seen  that  the  ole- 


DISLOCATIONS,   CONGENITAL   AND   ACQUIRED  .3i5 

cranon  projects  not  only  backward  but  above  a  transverse  line  ex- 
tending from  one  epicondyle  to  the  other.     It  should  be  on  a  level 


Fig.  119.  Incomplete  dislocation  of  both  bones  of  forearm  inward_  upon 
HUMERUS.  Boy  of  three  years.  Injury  by  fall  five  weeks  previously. 
Elbow  squared  instead  of  pointed,  and  upper  arm  shortened.  Olecranon 
internal  to  normal  position.  Flexion  and  extension  slight.  Pronation 
and  supination  of  forearm  free.  Considerable  lateral  motion  of  fore- 
arm upon  arm.     See  radiograph,  Fig.  120. 


Fig.  120.  Incomplete  dislocation  inward  of  radius  and  ulna 
UPON  humerus.  Boy  aged  3  years.  Radiograph  left  elbow  from  be- 
hind. Attempts  to  flex  forearm  separated  ulna  still  farther  from  radius, 
due  to   wedging  between   them   of   the   cartilaginous   trochlea. 


with  that  line  when  the  elbow  is  extended  and  below  it  when  the 
elbow  is  flexed.     The  only  injury  likely  to  be  confused  with  dislo- 


3i6  SURGICAL  DISEASES   OF   CHILDREN 

cation  is  separation  of  the  lower  epiphysis  of  the  humerus.  In  dis- 
location, to  flex  the  forearm  renders  the  projection  of  the  olecranon 
more  prominent,  while  in  epiphyseal  separation,  flexing  the  forearm 
decreases  the  prominence  at  the  point  of  the  elbow.  Dislocation  has 
flexion  and  extension  interfered  with,  and  has  no  crepitus.  In 
epiphyseal  separation  motion  is  free,  there  is  too  free  lateral  motion, 
and  crepitus  is  found. 

Treatment. — One  has  usually  found  reduction  easy  by  taking 
humerus  in  one  hand  and  radius  and  ulna  in  the  other,  straightening 
the  arm,  pulling  down  and  suddenly  flexing  while  the  traction  is  con- 
tinued. It  must  be  very  seldom  in  a  child  that  it  is  necessary  to 
bend  the  elbow  around  one's  knee.  Ordinarily  one  would  use  chlo- 
roform if  it  be  at  hand.  But  one  has  a  number  of  times  had  occa- 
sion to  reduce  an  elbow  without  it.  The  reduction  is  done  in  a  few 
seconds  and  relief  is  obtained.  However,  one  should  always  use 
chloroform  if  there  is  any  question  about  the  diagnosis  or  any  com- 
plication. When  reduced,  the  joint  is  freely  movable,  both  passively 
and  actively ;  and  there  is  no  reappearance  of  the  deformity.  With 
fracture  above  the  condyles  or  with  epiphyseal  separation,  the  de- 
formity reappears  when  released  from  the  surgeon's  grasp.  The 
patient  should  be  made  to  demonstrate  that  he  can  flex  the  arm  vol- 
untarily to  a  right  angle.  In  that  position  it  should  be  wrapped  in 
cotton  and  put  up  in  a  right-angled  splint  or  in  molded  binder's 
board  or  a  pasteboard  box  splint,  with  a  roller  bandage,  to  secure 
fixation,  and  carried  in  a  sling.  In  a  week  or  ten  days  passive  move- 
ments and  light  massage  are  begun  and  used  only  cautiously,  the 
splint  being  replaced,  with  slight  pressure  if  edema  continue.  I 
have  never  had  ankylosis  from  dislocation  at  the  elbow ;  but  think 
it  can  be  induced  by  too  early  and  too  much  motion,  and  leaving  off 
the  splint  and  rest  treatment  before  the  joint  has  fully  recovered. 

DISLOCATION   OF  RADIUS  AND  ULNA  FORWARD 

This  injury  is  a  rare  one.  Stimson,  writing  in  1900,  says  the  re- 
corded cases  are  less  than  twenty-five.  "  Of  the  thirteen  cases  in 
which  the  age  is  mentioned,  one  was  six  years  old,  two  were  eight, 
two  fourteen,  two  fifteen,  and  one  each  eighteen,  twenty,  twenty- 
four,  thirty-eight  and  forty  years  old.  One  was  an  '  adult '  and  one 
middle-aged."  Thus  seven  out  of  thirteen  presenting  this  rare  form 
of  dislocation  were  under  fifteen  years  of  age. 

The  most  common  cause  is  a  fall  upon  the  point  of  the  elbow 
with  the  arm  flexed;  but  various  forms  of  violence  are  recorded. 
The  dislocation  may  occur  without  or  with  fracture  of  the  olecra- 
non ;  and  it  may  be  incomplete  or  complete.  When  the  upper  end 
of  the  olecranon  rests  against  the  under  and  anterior  surface  of  the 
humerus  it  is  said  to  be  incomplete ;  but  if  the  end  of  the  olecranon 


DISLOCATIONS,   CONGENITAL   AND    ACQUIRED  317 

passes  up  in  front  above  the  end  of  the  humerus  the  dislocation  is 
called  complete. 

Symptoms. — In  the  incomplete  form  the  forearm  is  lengthened 
when  the  arm  is  extended  or  only  slightly  flexed.  In  the  complete 
form  the  forearm  is  lengthened  when  flexed  near  the  right  angle, 
but  more  or  less  shortened  when  extended.  The  sides  and  back  of 
the  elbow  are  flattened  and  a  space  can  be  felt  there  between  the 
humerus  and  the  ulna,  unless  there  is  too  much  swelling  present.  If 
the  two  epicondyles  can  be  located  the  presence  or  absence  of  the 
end  of  the  olecranon  from  its  normal  relative  position  can  usually 
be  determined. 

Treatment. — Reduction  can  be  efifected  in  the  incomplete  form 
by  pulling  the  arm  in  overextension  and  then  flexing ;  or  by  flexing 
it  round  the  surgeon's  knee.  In  the  complete  form,  while  the  joint 
is  full  flexed  over  the  surgeon's  index  and  middle  fingers,  he  pulls 
the  upper  end  of  the  forearm  downward  and  backward.  Or  a  strap 
may  be  used  instead  of  the  fingers.  The  elbow  is  then  put  up  as  for 
dislocation  backward. 

SUBLUXATION  OF  RADIUS 

This  is  the  most  peculiar  as  well  as  the  most  frequent  disloca- 
tion of  the  radius  in  the  young — admitting  that  it  is  a  dislocation  of 
the  radius.  The  question  of  the  exact  nature  of  this  injury  has  been 
long  and  frequently  discussed.  One  has  met  it  again  and  again  in 
dispensary  and  private  practice.  Every  surgeon  and  every  pedi- 
atrist  has  seen  numerous  cases.  Yet  there  has  never  been  an  op- 
portunity for  an  autopsy.  Here  is  a  typical  case:  A  man  playfully 
takes  a  three-year-old  child  by  the  wrists  and  proceeds  to  "  waltz," 
half  lifting  the  little  one  from  the  floor.  The  child  cries,  and  being 
released,  refuses  to  use  one  arm.  The  arm  hangs  at  the  side  slightly 
flexed  and  half  pronated.  The  arm  presents  nothing  abnormal  on 
inspection  or  on  palpation.  Flexion  and  extension  are  free.  Pro- 
nation is  also  free,  but  when  we  attempt  supination  there  is  a  cry 
and  something  prevents.  And  there  is  tenderness  over  the  head  of 
the  radius.  If  now  slight  force  be  used  to  supinate  the  forearm  and 
the  radial  head  be  pressed  backward,  there  is  a  snap,  and  the  trouble 
is  gone.  Reduction  can  also  be  effected  by  traction  on  the  forearm 
with  pressure  backward  on  the  head  of  the  radius,  followed  by  flex- 
ion ;  and  sometimes  by  supination  alone.  The  offered  explanations 
for  this  injury  are  curiously  various — displacement  forward,  dis- 
placement backward,  paralysis  from  injury  to  the  nerves,  catching 
of  the  bicipital  tuberosity  behind  the  ulna,  separation  of  the  head  of 
the  radius,  and  others.  The  most  satisfactory  explanation,  it  seems  to 
me,  is  that  of  Duverney,  who  considered  it  due  to  the  escape  of  the 
head  of  the  radius  downward  from  the  orbicular  ligament  by  trac- 


3iS  SURGICAL    DISEASES    OF    CHILDREN 

tion.  It  seems  probable,  however,  that  a  slight  twist  forward  of  the 
radius  tends  to  catch  the  head  at  the  edge  of  the  ring  once  it  is  out. 
In  several  of  my  cases  a  slight  fullness  in  front  of  the  radial  head 
was  detected;  and  the  manner  of  the  production  of  the  injury  seemed 
to  render  it  probable  that  in  addition  to  traction  upon  the  radius 
there  was  twisting  of  the  forearm.  For  instance,  a  child  was 
grasped  by  one  forearm  and  lifted  across  a  muddy  street.  Again, 
a  mother  putting  an  unruly  child  to  bed  undertook  to  make  him  fold 
his  arms.  The  accident  may  occur  by  forcible  adduction  of  the 
forearm  as  well  as  by  traction  in  the  long  axis.  I  believe  the  experi- 
ments of  Goyrand  and  Pingaud,  as  quoted  by  Stimson,  corroborating 
the  experimental  findings  of  Duverney,  together  with  clinical  obser- 
vation, satisfactorily  account  for  the  phenomena  observed  in  these 
cases.  Yet  the  question  is  not  considered  by  the  majority  to  be 
definitely  settled. 

Treatment. — If  left  entirely  to  itself  the  forearm  would  grad- 
ually recover  its  function,  possibly  with  the  formation  of  a  new  or- 
bicular ligament  or  something  resembling  it.  But  reduction  is  easily 
accomplished  as  before  described  and  at  once  gives  relief.  An 
anterior  rectangular  splint  well  padded  is  applied  and  the  arm  rested 
for  a  week. 

DISLOCATION   OF  THE  RADIUS  FORWARD 

Dislocation  of  the  head  of  the  radius  forward  occurs  from  falls 
upon  the  hand  or  upon  the  elbow  or  from  a  blow  upon  the  outer  and 
back  part  of  the  forearm  or  from  twisting  the  forearm.  The  head 
of  the  bone  projects  in  front  of  the  humerus,  and  flexion  beyond  a 
right  angle  is  impossible.  The  tendon  of  the  biceps  is  felt  to  be 
relaxed. 

Treatment. — Reduction  is  readily  accomplished  by  flexing  the 
forearm  and  pressing  the  head  of  the  radius  back  into  place.  It  has 
probably  torn  the  orbicular  ligament,  and  three  or  four  weeks  must 
be  given  for  its  repair.  The  dislocation  would  readily  recur  unless 
prevented.  A  rectangular  splint  applied  anteriorly,  with  the  arm 
well  flexed,  and  carried  in  sling,  prevents  this. 

DISLOCATION  OF  RADIUS  BACKWARD 

This  occasionall}-  occurs,  but  rarely.  It  can  generally  be  recog- 
nized by  feeling  the  head  of  the  radius  below  its  normal  place,  or 
below  and  behind  it  when  the  elbow  is  flexed,  and  behind  it  when 
the  joint  is  extended.  It  can  be  replaced  by  pressure  on  the  head 
of  the  bone ;  or  by  extension,  supination  and  pressure ;  or  by  exten- 
sion, traction,  adduction,  and  then  pressure  upon  the  head  of 
the  bone.  The  splint  just  described  for  dislocation  forward  will 
answer. 


DISLOCATIONS,    CONGENITAL    AND    ACQUIRED  319 

DISLOCATION  OF  THE  SHOULDER 

This  is  not  at  all  common  in  children.  The  force  which  in  an 
adult  would  dislocate  a  shoulder  would  probably  in  a  child  separate 
the  upper  epiphysis  of  the  humerus  or  cause  the  elbow  or  collar-bone 
to  yield,  as  any  of  these  injuries  are  more  frequent. 

DISLOCATION   OF  THE  HIP 

Dislocation  of  the  hip,  of  the  traumatic  variety,  is  very  seldom 
met  in  children.  When  it  does  occur,  it  presents  no  peculiarities 
which  require  attention  here.  It  is  generally  easily  reduced  by  ma- 
nipulation ;  and  the  same  treatment  would  be  suitable  as  in  the  adult. 

DISLOCATION   OF  THE  PATELLA 

Wright  reports  a  case  of  habitual  dislocation  of  the  patella, 
probably  due  to  congenital  weakness  and  ill-development  of  the 
parts.  Through  an  incision  he  anchored  the  patella  to  the  capsule 
by  two  catgut  sutures  at  its  inner  border. 

DISLOCATIONS  OF  THE  PHALANGES 

These  are  rather  frequent  in  children,  and  as  a  rule  receive  too 
little  surgical  attention.  They  are  pulled  at  by  parent  or  neighbor, 
and  unless  easily  reduced  further  damage  is  done.  When  incom- 
plete they  may  be  manipulated  into  place  with  great  ease.  When 
complete  the  finger  should  be  still  further  bent  in  the  position  in 
which  it  is  found,  while  the  margins  of  the  articular  surfaces  are 
placed  and  held  evenly  together;  then  with  extension  the  reduction 
is  effected.  If  a  portion  of  the  torn  capsule  intervene  and  prevent 
the  reduction,  the  joint  must  be  opened  antiseptically,  the  capsule 
W'ithdrawn,  reduction  eft'ected,  and  the  incision  closed. 

DISLOCATION  OF  THE  THUMB 

Only  the  complete  form  of  the  backward  dislocation  of  the 
proximal  phalanx  of  the  thumb  will  be  mentioned,  as  that  is  the  one 
that  is  notoriously  likely  to  prove  difficult  of  reduction.  Stimson 
considers  that  Farabeuf,  in  his  famous  and  much-quoted  presenta- 
tion of  the  subject,  has  overestimated  the  importance  of  the  sesa- 
moid bones  in  opposing  reduction.  He  considers  it  to  be  the  torn 
edge  of  the  anterior  ligament  tightly  drawn  across  the  back  of  the 
metacarpal  behind  its  head. 

Treatment. — The  muscles  of  the  thumb  should  be  relaxed  as 
much  as  possible  by  holding  the  hand  in  straight  extension  and  slight 
abduction,  and  the  thumb  strongly  adducted,  pressed  into  the  palm. 


320  SURGICAL   DISEASES    OF   CHILDREN 

Then  with  the  phalanx  standing  in  overextension  at  right  angles 
with  the  metacarpal  its  base  is  pressed  forward,  that  is,  in  the  distal 
direction,  until  its  dorsal  surface  is  level  with  the  end  of  the  meta- 
carpal, when  it  is  straightened.  If  the  reduction  does  not  occur  by 
this  means,  the  phalanx  may  be  rotated  while  it  is  being  extended 
and  flexed.  This  may  free  the  ligament  if  it  has  been  caught.  Not 
succeeding  by  this  maneuver,  arthrotomy  must  be  resorted  to  as 
preferable  to  violent  efforts  at  reduction  by  extension.  In  arthrot- 
omy the  incision  is  made  longitudinally  upon  the  projecting  head  of 
the  metacarpal,  the  wound  retracted  and  an  effort  made  to  lift  the 
long  flexor  tendon  and  with  it  the  torn  edge  of  the  ligament  from 
the  side  of  the  head  around  to  the  front.  If  this  does  not  free  the 
bones  the  margin  of  the  ligament  should  be  nicked  with  a  knife, 
when  it  will  be  released. 

DISLOCATIONS  OF  THE  STERNUM  AND  OF  THE  RIBS 

Very  unusual  in  children,  owing  to  the  softness  and  elasticity  of 
the  chest  walls.  Dislocation  of  the  manubrium  upon  the  body  of 
the  sternum  has  been  recorded,  and  also  dislocation  of  the  ziphoid  or 
ensiform  cartilage.  The  ribs  may,  by  great  violence,  be  dislocated 
from  the  vertebrae ;  and  occasionally  by  less  force  from  their  attach- 
ment to  the  sternum. 

COMPOUND    DISLOCATIONS 

Compound  dislocations  will  occasionally  occur  in  children  as 
in  adults,  often  with  very  serious  tearing  of  the  ligaments  and  ten- 
dons about  a  joint,  as  well  as  injury  of  vessels  and  nerves,  and  of 
course  adding  the  dangers  of  sepsis  of  an  open  wound.  Yet  one  has 
often  seen  joints  opened  by  dislocation,  or  dislocation  complicated 
with  fracture,  not  only  escape  gangrene  or  suppuration,  but  even 
very  great  deformity  by  ankylosis.  A  single  example  will  illustrate : 
Carl  D.,  a  boy  of  twelve  years,  fell  to  the  ground  with  a  heavy 
plank,  producing  a  compound  dislocation  of  the  right  elbow.  No 
doctor  could  be  found  at  once  and  my  arrival  was  two  hours  after 
the  accident.  Meanwhile  the  wound,  filled  with  dirt,  was  wrapped 
in  a  soiled  towel.  The  elbow  was  overextended,  the  articular  end 
of  the  humerus  was  thrust  out  through  a  wound  across  the  front 
of  the  elbow ;  the  anterior  and  both  lateral  ligaments  and  the  tendon 
of  the  biceps  were  torn  through.  The  brachial  artery  was  the  only 
structure  in  front  of  the  articulating  surface  of  the  humerus,  and 
was  stretched  as  tight  as  a  bow-string.  Forearm  pulseless.  Severe 
bruising  about  the  joint  caused  by  the  edge  of  the  plank.  Under 
anesthesia  the  joint  was  very  carefully  cleansed  with  antiseptics,  put 
in  place,  the  torn  structures  approximated  with  sutures,  drained 
with  a  strand  of  catgut,  dressed  with  iodoform  and  sterile  gauze, 


DISLOCATIONS,  CONGENITAL  AND  ACQUIRED  321 

put  up  in  a  right-angled  pasteboard  box  splint  and  elevated,  with 
ice  bags.  It  was  not  dressed  for  ten  days.  After  very  slight  passive 
motion  it  was  put  up  for  another  week.  After  twenty  days  from 
the  accident  passive  motion  was  carefully  practiced  regularly. 
Pronation  and  supination  became  perfect,  and  flexion  and  extension 
lacked  but  little  of  the  normal,  and  the  arm  appears  strong  as  ever. 
(See  also  remarks  upon  Amputation  for  Compound  Fracture,  in  the 
Chapter  on  Fractures.) 

MOTION  AFTER  DISLOCATIONS  AND  OTHER  JOINT 
INJURIES 

There  seems  to  be  a  tendency  on  the  part  of  many  practitioners 
to  exaggerate  the  dangers  of  ankylosis  after  dislocation  and  other 
injuries  of  joints;  and  their  fear  is  that  ankylosis  can  only  be  pre- 
vented by  putting  the  joint  to  use  very  promptly  after  the  injury 
with  passive  and  active  movements.  My  own  belief,  founded  upon 
observation  is  that  so  long  as  inflammation  remains  active  in  or 
about  an  injured  joint  or  so  long  as  the  condition  is  aggravated  by 
movements,  such  attempts  at  motion  not  only  gain  nothing  in  mo- 
bility but  actually  lessen  the  chances  of  a  satisfactory  end-result. 
It  is  far  better  to  allow  the  traumatic  inflammation  to  subside,  and 
the  wounded  soft  parts,  the  lacerated  capsule,  the  sundered  liga- 
ment to  become  reunited  before  attempting  to  establish  function. 
More  attention  should  be  centered  upon  accurate  reduction  without 
further  violence  to  the  structures,  upon  thorough  asepsis  in  com- 
pound injuries,  and  upon  retention  in  a  fixed  dressing  when  re- 
duced. The  adhesions  depend  upon  the  injury  and  the  inflamma- 
tion, and  attacking  them  soon  does  not  lessen  their  number;  while 
there  is  little  danger  that  more  time  will  render  them  too  strong  to 
be  broken.  It  may  give  more  confidence  in  nature's  power  to  pre- 
serve a  joint  to  remember  that  a  new  joint  can  be  produced  by  in- 
terposing fibrous  tissue  and  fat  between  bone  ends  and  beginning 
movements  not  sooner  than  two  weeks  after  the  operation ;  and  that 
false  joints  are  sometimes  spontaneously  produced  after  fracture ; 
and  that  when  false  joint  occurs  in  a  child  it  is  a  matter  of  diffi- 
culty to  eradicate  it  and  secure  rigid  union. 


CHAPTER  XII 

SURGICAL    DISEASES    OF    THE    LYMPHATICS 

The  Status  Lymphaticus  (Lymphatism) — Hyperplasia  of 
THE  Lymph  Tissues  of  the  Pharynx  and  Naso-pharynx — ■ 
Primary  and  Secondary  Tumors  of  the  Lymph  Vessels 
AND  OF  the  Lymph  Glands — Lymphangiectasis,  Lympha- 
denoma  and  Lymph  Varix — Simple  Acute  Lymphadenitis 
— Acute  Septic  Lymphadenitis — Simple  Chronic  or  Sub- 
acute Lymphadenitis— Tubercular  Lymphadenitis — Syph- 
ilitic Lymphadenitis — Hodgkin 's  Disease. 

It  seems  to  be  natural  for  the  lymphatic  tissues  to  be  very 
active  in  early  life.  To  this  normal  activity  are  added  very  numer- 
ous causes  of  irritation,  such  as  inherited  dyscrasise,  local  inflamma- 
tions upon  the  skin  and  upon  the  mucous  linings  of  the  naso- 
pharynx, the  mouth,  the  respiratory  and  gastro-intestinal  tracts, 
and  to  a  lesser  degree  the  genitalia ;  besides  the  many  infectious 
agents  that  And  a  fertile  soil  in  the  tender  organism  of  the  young, 
which  has  as  yet  developed  no  immunizing  power;  moreover,  there 
are  sometimes  new  growths  in  connection  with  the  lymph  glands. 
So  that  we  find  these  glands  very  often  the  seat  of  morbid  condi- 
tions requiring  the  attention  of  the  surgeon.  Some  of  the  lymph- 
nodes  are  so  situated  as  to  preclude  surgical  interference;  but  all 
those  externally  located  are  accessible,  and  constantly  dealt  with 
surgically,  while  the  internal  are  frequently  to  be  considered  in 
diagnosis  and  sometimes  in  treatment.  Different  groups  of  glands 
are  most  affected  at  different  ages  and  stages  of  development 
as  well  as  pathological  history,  which  is  more  or  less  a  matter  of 
accident  as  well  as  of  heredity.  For  instance,  enlargement  of  post- 
pharyngeal adenoids  and  tonsils  may  be  found  at  any  age  up  to 
puberty,  when  there  is  a  tendency  to  atrophy.  During  infancy, 
when  gastro-intestinal  and  bronchial  mucous  membranes  are  so 
frequently  diseased,  the  lymph-nodes  in  their  proximity  keep  pace. 
A  little  later,  when  carious  teeth  are  common  and  diphtheria,  mea- 
sles, scarlet  fever,  and  other  acute  infections  affect  the  mouth, 
nares,  pharynx  and  ears,  and  parasites  infest  the  scalp,  the  lymph- 
nodes  near  by  in  the  cervical  region  present  the  most  pathological 

322 


SURGICAL   DISEASES    OF  THE   LYMPHATICS  323 

conditions.  At  any  age,  but  more  especially  after  the  catarrhal 
inflammations  of  the  mucous  surfaces  already  mentioned  have  ren- 
dered them  vulnerable,  the  lymph-nodes  afford  a  lodging  place  for 
the  tubercle  bacillus,  and  become  the  seat  of  its  activity. 

Pediatric  surgery  of  the  lymphatics  will  be  considered  under 
the  following  headings:  The  status  lymphaticus  Hyperplasia  of 
the  lymph  tissues  of  the  pharynx  and  naso-pharynx ;  Primary  and 
secondary  tumors  of  the  lymph  vessels  and  of  the  lymph  glands ; 
Lymphangiectasis,  lymphadenoma  and  lymph  varix ;  Simple  acute 
lymphadenitis ;  Acute  septic  lymphadenitis ;  Simple  chronic  or  sub- 
acute lymphadenitis ;  Tubercular  lymphadenitis ;  Syphilitic  lymph- 
adenitis ;  Hodgkin's  disease. 

THE    STATUS    LYMPHATICUS     (LYMPHATISM) 

By  some  writers  lymphatism  is  used  to  designate  that  which  we 
formerly  called  struma  or  scrofula  after  all  that  is  due  to  the  tubercle 
bacillus  has  been  differentiated  from  it — in  other  words,  an  over- 
development and  vulnerability  of  the  lymphatic  system  and  with  it 
of  the  mucous  membranes.  Others  use  lymphatism  as  synonymous 
with  status  lymphaticus,  which  latter,  perhaps,  would  best  be  re- 
served, as  the  name  of  an  extreme  expression  of  that  diathesis  in 
which,  in  addition  to  the  lymphatic  hyperplasia,  there  is  hypertrophy 
of  the  thymus,  called  by  some  the  status  thymicus. 

Etiology. — The  "  status  lymphaticus  "  may  or  may  not  be  a 
variety  of  "  lymphatism  "  or  "  struma  "  (used  in  its  modern  sense)  ; 
nor  is  it  known  whether  it  bears  a  relationship  to  rickets,  although 
frequently  associated  with  it.  Nor  is  it  certainly  known  how  much 
the  enlargement  of  the  thymus  has  to  do  with  the  disease,  nor  what 
causes  the  enlargement,  nor,  if  it  produces  the  symptoms,  how  they 
are  brought  about.  The  disease  is  most  frequent  in  the  second  half 
year  of  life,  but  may  be  found  at  any  age.  The  pathological  findings 
are  hyperplasia  of  the  lymph-nodes,  especially  those  of  the  tracheo- 
bronchial region  and  the  pharynx,  enlargement  of  the  solitary  folli- 
cles of  the  intestines  and  of  Peyer's  patches;  enlargement  of  the 
spleen,  and  of  the  thymus  gland.  This  last  is  very  remarkable. 
Accordng  to  Bovaird  and  Nicoll,  as  quoted  by  Holt,  the  weight  of 
the  normal  thymus  at  birth  is  from  6  to  7  grams ;  from  birth  to  five 
years  from  3  to  4  grams,  and  anything  over  10  grams  should  be 
considered  as  distinctly  abnormal.  In  marked  cases  of  the  status 
lymphaticus  the  thymus  weighs  from  30  to  40  grams ;  in  the  less 
marked,  from  10  to  20  grams.  It  shows  no  other  change  than  hyper- 
plasia. Some  observers  have  found  also  hypoplasia  of  the  heart 
and  aorta ;  but  whether  this  is  a  coincidence  or  bears  any  relation 
to  the  lymphatic  state  is  not  clear.  (22) 

Symptoms. — In  some  cases  nothing  of  the  kind  is  suspected 


.•524  SURGICAL    DISEASES    OF    CHILDREN 

as  being  present,  until  some  trivial  operation  such  as  paracentesis 
thoracis  or  the  administration  of  antitoxin  or  of  chloroform  is 
undertaken,  when  the  child  promptly  dies.  In  other  cases  symptoms 
appear  like  the  onset  of  an  acute  illness — with  convulsions  as  a  prom- 
inent feature,  or  it  may  be  dyspnea  with  cyanosis  or  asphyxia,  with 
high  fever,  and  death  in  a  day  or  two  without  the  development  of 
any  recognizable  disease  aside  from  the  status  lymphaticus.  Or  the 
disease  may  be  recognized  in  life  by  the  tendency  to  convulsions, 
the  dyspneic  attacks,  the  lymphatic  hyperplasia,  enlarged  spleen  and 
thymus  gland,  which  latter  may  sometimes  be  so  large  as  to  cause 
substernal  dullness. 

It  is  not  known  whether  the  dyspnea  is  due  to  pressure  of  the 
large  thymus  upon  the  recurrent  laryngeal  nerve,  or  upon  the  trachea 
or  the  lungs,  or  the  auricles  of  the  heart ;  or  whether  death  occurs 
from  pressure  on  the  pneumogastric  or  the  heart  or  aorta.  It  has 
been  demonstrated  in  at  least  one  case  that  a  hypertrophic  thymus 
can  compress  the  trachea  and  cause  mechanical  stenosis.  (Jack- 
son.) In  other  cases  there  are  no  characteristic  symptoms  in  the 
fatal  illness,  but  the  child  shows  but  feeble  resistance  to  an  appar- 
ently trifling  ailment  and  soon  succumbs,  and  the  findings  at  the 
autopsy  are  those  of  the  status  lymphaticus.  (See  also  section  on 
Thymic  Tracheostenosis.) 

Diagnosis. — If  the  disease  is  sufficiently  well  marked  for  diag- 
nosis it  can  be  recognized  by  the  symptoms  just  described.  The 
greatest  importance  to  the  surgeon  in  its  diagnosis  is  to  avoid 
anesthesia  or  operation  or  any  possible  cause  of  shock  in  a  child 
of  this  type,  unless  the  condition  is  such  as  to  justify  far  more  than 
the  ordinary  risks  attendant  upon  such  procedures.  (23) 

Treatment. — The  dyspnea  may  apparently  call  for  intubation 
or  tracheotomy,  but  these  operations  do  not  give  relief.  There  have 
been  a  few  cases  operated  upon,  opening  the  chest  by  raising  a 
portion  of  the  sternum,  attaching  the  thymus  thereto,  and  so  reliev- 
ing the  pressure  of  the  weight  of  the  organ  and  the  intra-thoracic 
pressure.  The  general  treatment  is  by  fresh  air,  sunlight,  nutri- 
tious food,  cod-liver  oil  and  iodides,  especially  the  syrup  of  ferrous 
iodide. 

HYPERPLASIA    OF    THE    LYMPH    TISSUES    OF    THE 
PHARYNX    AND    NASOPHARYNX 

These  will  be  discussed  in  the  chapter  on  Surgery  of  the  Air 
Passages. 

PRIMARY  AND  SECONDARY  TUMORS  OF  THE  LYMPH 
VESSELS  and'  of  THE  LYMPH  GLANDS 

These  are  considered  in  the  chapter  on  Tumors,  in  the  sections 
on  Lymphoma,  Lymphangioma  and  Carcinoma.  The  differential 
diagnosis  from  adenitis  will  appear  in  the  present  chapter  in  the 


SURGICAL    DISEASES    OF    THE    LYMPHATICS  325 

section  on  Tubercnlar  Lymphadenitis.  Primary  Sarcoma  will  be 
considered  here. 

Primary  Sarcoma  of  the  lymphatic  glands  is  rare.  It  is  an 
elastic  swelling,  perfectly  smooth  and  movable  as  long  as  the  cap- 
sule of  the  affected  gland  remains  intact.  The  glands  adjacent  to 
the  first  one  become  involved,  and,  later,  the  cells  of  the  sarcoma 
migrating  in  the  lymph  current,  general  infection  takes  place  and 
metastatic  tum.ors,  with  the  same  small  round  cells  in  a  very  fine 
lattice  stroma,  appear  in  various  regions.  The  primary  tumor  es- 
capes from  the  gland  capsule  and  involves  the  periglandular  tissue 
and  finally  the  skin  and  ulcerates  and  sloughs. 

Lymphosarcoma  is  differentiated  from  tlodgkin's  disease  by 
the  absence  of  general  lymph  hyperplasia  in  all  parts  of  the  body, 
including  enlargement  of  the  liver  and  spleen,  and  absence  of  the 
anemia ;  from  leukemia  by  absence  of  the  blood  picture  character- 
istic of  the  latter  disease ;  from  tubercular  glands  by  the  rapid 
growth  of  the  sarcoma. 

Treatment  is  by  extirpation,  and  even  this  gives  a  grave  prog- 
nosis, as  recurrence  is  the  rule,  unless  the  operation  is  done  early, 
while  the  growth  is  still  within  the  capsule  of  the  gland.  Senn 
makes  it  particularly  emphatic  that  sarcomatous  glands  should 
never  be  enucleated  even  if  the  capsules  have  not  been  perforated 
by  the  growth ;  as  sarcoma  cells  have  undoubtedly  already  passed 
out  into  the  surrounding  connective  tissue.  Therefore  the  con- 
nective tissue,  as  well  as  the  glands,  should  be  excised.  No  blunt 
dissection  should  be  used,  and  not  only  glands  and  connective  tissues, 
but  even  arterial  and  nerve  trunks  and  every  structure  implicated  in 
the  growth,  should  be  removed.  (See  also  general  Section  on 
Sarcoma  in  Chapter  on  Tumors.) 

LYMPHANGIECTASIS,  LYMPHADENOMA  AND  LYMPH 

VARIX 

Lymphangiectasis  is  a  condition  of  local  dilatation  of  the  lymph 
vessels  due  to  damming  their  fiow^  The  obstruction  may  be  due  to 
inflammation  affecting  the  vessels  themselves  or  to  pressure  from 
an  outside  source,  such  as  a  tumor — primary  or  secondary,  ascites,  a 
ligature  or  surgical  appliance,  or  to  scar  tissue. 

Lymphangiectasis,  or,  as  it  is  sometimes  called  wdien  aft"ecting 
the  glands,  lymphadenoma,  may  be  parasitic  in  origin,  being  most 
frequently  due  to  the  presence  of  the  filaria  sanguinis  hominis,  a 
minute  nematode  worm  native  in  the  tropics,  wdiich  lives  in  tlie 
lymphatics  and  blood-vessels.  Elephantiasis  is  a  form  of  the  dis- 
ease. 

Lymph  varix  is  a  dilated  tortuous  lymi)hatic  vessel  resulting 
from  any  occlusion,  mechanical  or  parasitic. 


326  SURGICAL   DISEASES    OF    CHILDREN 

SIMPLE   ACUTE   LYMPHADENITIS 

This  is  an  acute  inflammation  of  the  lymph-nodes  which  ter- 
minates in  resolution,  in  suppuration,  or  in  chronic  inflammation, 
according  to  the  age  of  the  patient,  his  vital  resistance  and  the 
nature  of  the  infecting  agent. 

The  external  nodes  of  the  cervical  region,  axilla  and  groin  are 
the  ones  with  which  the  surgeon  most  frequently  has  to  deal  in 
acute  inflammation.  This  occurs  from  simple  catarrhs  of  the 
mucous  membranes,  in  connection  with  measles,  German  measles, 
scarlet  fever,  diphtheria,  in  any  form  of  stomatitis  producing  a 
solution  of  continuity,  in  tonsilitis,  in  connection  with  carious  teeth, 
herpes,  ecthyma,  eczema,  w^ounds,  otorrhoea.  In  the  axillary  glands 
it  is  often  produced  from  slight  trauma  upon  hand  or  arm  or  from 
vaccination ;  in  the  inguinal  region  from  wounds  of  the  lower 
extremity,  balanitis  or  vaginitis.  In  some  of  these  inflammations, 
no  doubt,  the  irritation  is  produced  by  the  absorption  of  toxins 
which  are  carried  to  the  gland,  while  in  others  the  germs  them- 
selves, possibly  the  specific  organism  of  the  infective  fevers,  but 
usually  staphylococci  or  streptococci,  are  lodged  there.  The  aflfected 
glands  become  acutely  congested  and  swollen,  hyperplastic,  edema- 
tous, and  the  result  will  depend  on  the  nature  of  the  irritant  and  the 
resisting  power  of  the  cells. 

In  infants  such  inflammations  more  frequently  result  in  sup- 
puration than  in  older  children.  But  at  any  age  the  presence  of 
pyogenic  organisms,  especially  a  mixed  infection  or  the  scarlet 
fever  poison,  may  overpower  the  resistance  of  the  cells  and  abscess 
will  result. 

Quite  frequently  one  can  discover  by  searching  the  field  drained 
by  the  affected  gland  or  group  of  glands  the  atrium  of  infection. 
But  sometimes  the  primary  disease  or  lesion  has  passed  by  and  left 
only  the  lymphatic  inflammation  as  a  sequela.  The  symptoms  are 
those  of  the  original  disease,  and  of  swelling  and  tenderness  over 
the  inflamed  glands.  If  the  inflammation  is  not  very  severe  or  ad- 
vanced, the  gland,  although  large,  perhaps  as  large  as  a  filbert  or 
an  olive,  is  quite  movable.  But  if  the  inflammation  become  so  severe 
that  suppuration  threatens,  the  periglandular  cellular  tissues  are 
involved,  and  gland  and  cellular  tissues  become  a  brawny  mass, 
tenderness  increases,  with  heat  and  pain,  finally  fluctuation,  and  if 
left  to  itself  redness  and  breaking  down  of  the  skin,  discharge  of 
pus  and  later  healing.  Redness  may  be  present  before  fluctuation 
in  the  dense  mass  can  be  detected,  and  the  whole  process  may  require 
two  to  four  weeks  before  the  abscess  has  discharged  or  suppurated 
ready  to  be  opened.  Sometimes  the  inflammation  is  communicated 
from  gland  to  gland  and  the  process  greatly  extended  in  area  and 


SURGICAL   DISEASES    OF   THE   LYMPHATICS  327 

prolonged  in  time.  It  sometimes  appears  as  though  the  cases  which 
do  not  suppurate  take  as  long  to  recover  as  those  in  which  suppura- 
tion occurs,  and  even  then  their  state  of  health  may  not  be  quite 
satisfactory. 

Treatment  includes  that  of  the  field  of  absorption,  which  should 
be  cleansed  and  rendered  sound  as  speedily  as  possible  to  avoid 
further  poisoning  of  the  lymphatics.  For  the  swollen  glands  them- 
selves many  applications  are  recommended.  None  of  them  seem 
to  have  the  power  of  preventing  suppuration  if  it  is  ready  to  occur, 
but  treatment  may  moderate  the  inflammation  and  mitigate  the  dis- 
comfort, and  if  it  cannot  abort  may  hasten  the  process  to  a  favorable 
termination.  Cold  in  the  form  of  an  ice  bag  is  useful  in  sthenic 
cases,  that  is,  in  fairly  robust  children  with  high  fever  and  con- 
siderable reactive  power,  and  especially  early  in  the  case  before  sup- 
puration becomes  inevitable.  Heat  is  better  in  the  opposite  class 
of  cases,  the  feeble  children  of  low  vitality,  and  in  all  cases  in  the 
later  stages.  The  drug  applications  one  sees  recommended  are 
iodine,  in  the  form  of  the  tincture  painted  on,  or  of  the  ointment 
of  the  iodide  of  lead,  the  unguentum  Crede,  etc.  I  have  seen  as 
good  effects  from  the  use  of  guiacol,  10  to  25  per  cent.,  with  lanolin 
and  lard,  or  of  mercurial  ointment,  as  from  any  other  application, 
and  think  these  have  some  power  to  limit  the  spread  into  cellular 
tissues.  But  my  rule  is  never  to  apply  anything  which  makes  the 
skin  sore  or  will  interfere  with  its  proper  examination  or  incision 
at  the  proper  stage.  The  proper  stage  for  incision  is  not  until 
suppuration  has  occurred  and  the  abscess  has  pointed.  The  early 
incision  of  these  inflamed  glands  can  do  no  good  and  may  do  harm 
and  does  not  hasten  the  cure.  The  only  condition  at  all  similar  in 
which  early  incision  is  useful  is  Ludwig's  angina — a  diffuse  septic 
cellulitis  (which  see).  In  lymphadenitis  the  disease  process  is  bemg 
limited  by  nature's  barriers.  And  to  excise  early  an  inflamed  gland, 
while  it  might  eliminate  the  trouble,  is  not  devoid  of  danger,  and 
may  fail  to  eradicate  the  disease  which  probably  has  already  found 
its  way  to  other  glands.  When  the  abscess  has  formed,  before 
waiting  for  destruction  of  the  skin,  an  incision  should  be  made. 
General  anesthesia  is  not  usually  necessary  for  the  opening  of  such 
an  abscess.  The  ethylchloride  spray  locally  is  sufficient.  That 
point  should  be  chosen  for  the  incision  which,  while  it  will  enter 
the  abscess  directly  and  afford  the  best  drainage,  will  be  the  least 
conspicuous.  The  situation  of  the  abscess,  of  course,  may  vary,  but 
a  frequent  site  is  in  the  sub-parotid  lymphatics,  and  the  abscess 
points  at  that  level,  but  behind  the  sterno-mastoid.  It  may  burrow 
under  that  muscle,  especially  if  allowed  to  wait  too  long,  and  point 
in  front  of  it  but  lower  down.  The  posterior  situation  is  usually  the 
better  situation  for  opening.     The  incision  should  be  made  in  the 


328  SURGICAL  DISEASES   OF   CHILDREN 

direction  of  the  skin-folds,  which  in  that  situation  run  obliquely 
upward  and  backward.  In  opening  a  submaxillary  abscess  one 
should  avoid  the  facial  artery,  and  also  avoid  the  inframaxillary 
branch  of  the  cervicofacial  nerve,  by  keeping  a  finger-breadth  below 
and  parallel  with  the  ramus  of  the  jaw.  The  abscess  being  emptied, 
it  is  not  necessary  nor  always  safe  to  curette  it.  A  small  drain  of 
catgut  should  be  introduced,  and  moist  dressing  used  to  facilitate 
drainage.     Healing  is  usually  prompt  and  the  scar  insignificant. 

Many  surgeons  are  now  treating  adenitis  with  suction  hyper- 
emia by  means  of  cupping  glasses.  (Bier-Klapp  method.)  If 
pus  is  present  it  is  evacuated  through  a  small  incision  (i  to  1.5 
c.  m.)  and  suction  applied.  If  abscess  has  not  formed  the  cup 
is  applied  at  once,  and  suction  made  strongly  enough  to  induce  a 
red,  not  a  blue,  swelling  and  to  cause  no  pain,  the  cup  being  left  on 
five  minutes.  The  cup  is  then  removed  and  after  an  interval  of 
three  minutes  is  again  applied  as  before  during  five  minutes.  This 
alternate  suction  of  five  minutes  and  rest  of  three  minutes  is  con- 
tinued for  twenty  to  forty-five  minutes  daily.  No  drainage  is  used. 
Cures  are  noted  in  seven  to  ten  days,  without  scar,  in  cases  which  in 
the  judgment  of  the  surgeon  would  have  persisted  two  or  three  times 
as  long  and  caused  much  pain,  extension  of  the  inflammation  and 
destruction  of  tissue  if  left  untreated  or  treated  by  other  methods. 

ACUTE    SEPTIC    LYMPHADENITIS 

This  will  be  found  described  in  the  Section  on  Cellulitis  in  an 
earlier  chapter. 

SIMPLE  CHRONIC  OR  SUBACUTE  LYMPHADENITIS 

This  is  a  simple  hyperplasia  of  the  lymphatic  glands,  excited 
in  the  same  manner  as  the  acute  form,  and  kept  up  by  the  continu- 
ous irritation  of  a  chronic  disease  of  mucous  membrane  or  skin, 
or  by  some  constitutional  dyscrasia,  often  that  which  is  called  struma 
yet  is  not  tuberculosis,  or  is  sometimes  called  lymphatism.  The 
cervical  glands  again  are  the  ones  most  often  involved,  especially 
in  the  cases  with  post-nasal  lymph  growths  and  enlarged  tonsils. 
There  is  no  fever  nor  pain  nor  tenderness.  The  swelling  increases 
slowly  during  several  weeks  or  months.  The  enlarged  glands  are 
movable  and  feel  elastic,  almost  resembling  fluctuation.  They  do 
not  suppurate  nor  mat  together  nor  implicate  the  skin,  nor  caseate. 
After  weeks  or  months  they  slowly  subside  to  the  size  of  navy  beans 
or  split  peas. 

Diagnosis. — The  diagnosis  of  this  condition  is  a  matter  of  some 
importance  on  account  of  its  resemblance  to  tubercular  adenitis.  It 
may  be  impossible  to  distinguish  between  the  two  without  a  tuber- 
culin test.    Yet  if  one  can  get  a  reliable  history  or  keep  the  patient 


SURGICAL   DISEASES    OF   THE   LYMPHATICS  329 

under  observation  long  enough  a  diagnosis  can  usually  be  made.  In 
the  simple  form  one  can  generally  find  an  exciting  cause  either  pasi 
or  present ;  and  treatment  directed  toward  that  cause,  for  instance, 
removal  of  adenoids  or  tonsils,  or  constitutional  treatment  for 
lymphatism,  makes  an  impression  on  the  enlarged  glands.  Although 
the  glands  enlarge  slowly,  the  process  is  not  as  slow  as  that  which 
occurs  in  the  tubercular  form,  unless  the  latter  be  a  mixed  infection. 
The  simple  subacute  form  shows  no  tendency  to  suppurate  unless 
lighted  up  by  a  re-infection  rendering  it  acute.  The  glands  do  not 
adhere  to  each  other  and  to  the  cellular  tissues  nor  to  the  skin. 

Treatment. — Removal  of  local  exciting  causes  and  the  same 
hygienic  management  as  that  recommended  for  lymphatism  or 
struma ;  open  air,  sunlight,  warm  clothing,  nutritious  food,  active 
excretions,  often  if  possible  a  change  to  the  seaside,  the  country  or 
the  mountains.  Among  drugs  there  is  nothing  better  than  the 
syrup  of  ferrous  iodide,  and  cod-liver  oil.  In  dispensary  practice 
a  mixture  of  these  two,  with  syrup  of  the  lacto-phosphate  of  lime, 
shaken  together,  makes  a  very  inelegant  but  efficient  preparation. 
No  operation  upon  the  nodes  is  called  for.  There  may  be  something 
to  do  in  the  naso-pharynx,  the  mouth.  Eustachian  tube  or  middle 
ear. 

TUBERCULAR    LYMPHADENITIS 

This  is  the  principal  feature  of  what  was  formerly  called 
scrofula  and  later  struma,  but  is  now  named  in  accordance  with  its 
cause,  the  tubercle  bacillus.  Lymphadenitis  may  be  present  in  con- 
junction with  other  manifestations  of  the  infection  or  it  may  be 
the  only  one.  While  any  of  the  lymphatics  may  be  the  seat  of  tuber- 
culosis it  is  only  those  of  the  neck,  the  axilla,  groin  and  abdomen 
that  concern  us  surgically.  Of  these  the  cervical  by  far  the  most 
frequently  need  attention.  The  periods  of  childhood  and  youth 
present  the  most  cases,  infants  seldom  showing  tuberculosis  in  this 
form,  although  they  frequently  have  mesenteric  or  bronchial  tuber- 
cular lymphadenitis,  especially  the  latter.  The  frequency  with  wdiich 
the  cervical  lymph-nodes  are  involved  is  accounted  for  by  their  prox- 
imity to  the  oro-naso-pharynx  and  accessory  cavities,  which  form 
the  gateway  for  the  entrance  of  the  germs ;  and  the  age  at  which 
these  glands  are  most  frequently  attacked  by  tuberculosis  is  just 
the  age  at  which  the  mucous  linings  of  those  tracts  are  most  fre- 
quently in  a  state  of  catarrhal  inflammation,  and  they,  as  well  as  the 
lymphatics,  most  frequently  irritated  by  the  poisons  of  the  exanthe- 
mata and  other  infections.  In  the  case  of  the  mesenteric  lymph- 
nodes  there  has  almost  invariably  been  previously  an  ulceration  of 
the  mucous  lining  of  the  intestines.  As  to  the  order  of  involvement, 
Holt  quotes  Nicoll's  statement  that  the  first  afifccted  are  most  fre- 
quently the  upper  set  of  the  deep  cervical  group ;  sometimes  the 


330  SURGICAL    DISEASES    OF    CHILDREN 

superficial  nodes  of  the  submaxillary,  or  the  parotid  group,  and  oc- 
casionally the  submental  of  the  preauricular.  One's  own  observa- 
tion would  lead  to  the  belief  that  the  subparotids  are  probably  the 
most  often  affected  in  the  beginning',  judging  by  their  showing  the 
most  advanced  changes. 

Pathology. — There  is  usually  if  not  invariably  more  than  one 
gland  involved,  and  quite  frequently  it  is  a  group  or  a  complete 
chain,  the  disease  gradually  extending.  Since  lymphadenitis,  which 
finally  proves  to  be  tubercular,  so  often  follows  subacute  or  chronic 
lymphadenitis,  the  question  arises  whether  such  cases  were  origi- 
nally tubercular.  Doubtless  many  cases  begin  with  the  tubercular 
infection,  and  many  pursue  a  very  chronic  course,  with  no  ten- 
dency to  cheesy  degeneration,  and  then  later  show  more  of  the 
characteristics  of  tubercular  inflammation.  But  there  is  nothing 
to  prove  that  a  simple  chronic  inflammation  may  not  have  preceded 
a  tubercular  involvement.  It  is  also  true  that  nodes,  the  seat  of 
either  simple  chronic  hyperplasia  or  of  tuberculosis,  may  take  on  an 
acute  inflammation  and  change  their  slow  course  to  the  rapid  forma- 
tion of  abscess.  It  should  be  stated,  however,  that  experiments 
have  proved  that  sometimes  chronically  enlarged  nodes,  like  the 
melon  seed  bodies  in  synovitis,  which  do  not  betray  tuberculosis  to 
the  microscope,  produce  the  disease  by  inoculation  into  guinea-pigs. 
The  bacilli  can  generally  be  found  in  the  early  and  active  stages  of 
the  inflammatory  process.  When  the  stage  of  complete  softening 
has  been  reached  the  abscess  contents  may  be  quite  sterile. 

Tuberculous  nodes  enlarge  to  the  size  of  birdshot  or  peas  or 
beans,  or  even  of  olives  or  hickory  nuts.  It  is  usual  to  find  one  or 
two  quite  larger  than  all  the  rest.  Dowd  ^  gives  a  good  description 
of  the  appearances  on  section  of  these  enlarged  nodes.  First,  those 
showing  soft  pinkish  gray  surfaces  of  almost  uniform  consistency, 
but  with  the  trabeculse  of  the  nodes  faintly  marked.  This  variety  ap- 
pears early  in  the  inflammation,  and  may  be  not  a  separate  variety 
but  rather  a  stage  which  will,  after  a  shorter  or  longer  time,  merge 
into  the  second  variet3^  which  shows  spots  of  necrosis  of  greater  or 
less  extent,  the  tissue  surrounding  the  spots  being  similar  to  that  of 
the  first  variety.  This  second  or  necrotic  variety  is  by  far  the  most 
common.  The  third  variety  of  node  shows  the  interior  entirely  broken 
down  into  granular  grayish  material  which  is  retained  by  the  capsule 
of  the  node.  This  is  regarded  as  an  uncommon  variety.  In  the  sing'le 
case  observed  each  node  capsule  was  filled  with  material  which 
looked  like  caked  meal,  no  proper  node-parenchyma  being  apparent. 
The  microscope  showed  this  soft  material  to  be  studded  with  tuber- 
cle. The  changes  which  take  place  in  the  glands,  as  recorded  by 
many  observers,  resemble  those  usual  in  tubercular  inflammations 

1  Bryant    and    Buck,    American    Practice    of    Surger}-,   Vol.    IL,    p.    545. 


SURGICAL   DISEASES   OF   THE   LYMPHATICS  331 

elsewhere,  namely,  the  i:)rohferation  of  the  epithelioid  and  the  giant 
cells,  the  surrounding-  zone  infiltrated  with  round  cells,  and  the 
cheesy  degeneration  beginning  at  the  center  of  the  focus.  There  may 
be  a  single  focus  in  a  node  or  numerous  foci  which  in  the  destruc- 
tive process  coalesce,  producing  an  abscess  cavity.  The  content 
of  tubercular  abscess  in  glands  as  in  other  tissues  is  not  true  pus. 
Unless  th^re  is  a  mixed  infection,  it  contains  no  pus,  but  the  soft- 
ened material  of  the  broken-down  node.  As  the  inflammation  ap- 
proaches the  gland  capsule  the  periglandular  structures  become  in- 
volved, neighboring  glands,  the  sheaths  of  vessels  and  nerves,  the 
intermuscular  fascise,  cellular  tissue,  or  skin,  become  matted  to- 
gether in  an  irregular  mass  in  which  the  softening  glands  are  em- 
bedded. When  the  capsule  opens,  the  "  pus  "  escapes,  and  if  not 
immediately  beneath  the  skin  it  burrows  in  the  cellular  tissues  until 
it  finds  the  surface.  The  skin  becomes  livid  or  deep  red,  softens  and 
breaks  down.  The  abscess  discharges,  and  sometimes  continues  dis- 
charging for  weeks  or  months,  closing  temporarily  and  reopening. 
The  edges  of  the  opening  are  bluish  red,  and  undermined.  If  the 
abscess  has  healed  there  is  left  a  puckered  and  unsightly  scar, 
adherent  and  contracted,  with  pits  and  ridges,  and  a  purple  discol- 
oration which  may  in  time  fade  out.  In  some  cases  the  tubercular 
process  in  th.6  glands  is  one  of  fibrosis.  The  glands  become  hard 
fibrous  masses,  containing  encapsulated  caseous  or  calcareous 
masses.  Whole  groups  or  chains  of  such  dense  and  knotted  glands 
may  remain  quiescent.  In  a  given  case  not  all  the  affected  glands 
undergo  the  same  process  simultaneously.  The  different  glands 
may  be  found  in  various  stages.  And  the  character  and  rate  of 
progress  and  termination  of  the  disease  will  vary  with  the  vitality, 
the  resisting  power  of  the  patient,  the  effect  of  other  local  irritations 
or  infections  and  of  intercurrent  diseases,  and  doubtless  with  the 
virulence  of  the  original  infection.  In  short,  the  history  of  tuber- 
cular inflammation  in  the  lymphatic  glands  is  similar  to  that  of 
the  lungs  and  other  tissues  of  like  vascularity ;  it  may  end  in  resolu- 
tion, encapsulation,  calcification  or  suppuration.  It  usually  presents 
coagulation  necrosis,  caseation,  and  liquefaction  of  the  cheesy  prod- 
uct. Other  tubercular  lesions  may  be  found  in  the  same  patient; 
or  if  the  lymphatic  infection  was  primary  it  may  run  its  course  as 
a  local  disease,  and  terminate  without  extending  to  any  other  part 
or  organ. 

Symptoms  and  Diagnosis. — Gradual  swelling,  slowly  but  per- 
sistently increasing,  is  the  only  symptom  of  the  beginning.  Ten- 
derness may  be  absent  unless  there  is  an  exacerbation  due  to  some 
intercurrent  irritation  of  another  kind.  The  swelling  continues  for 
several  months,  appearing  behind  or  in  front  of  the  sterno-mastoid 
muscle  about  or  a  little  above  its  middle.  One  or  several  glands  may 


332  SURGICAL    DISEASES    OF    CHILDREN 

be  palpated  as  cherry  or  olive-sized  movable  tumors  elastic  or  firmer 
in  different  cases.  If  a  gland  is  destined  to  suppurate,  the  peri- 
glandular inflammation  and  adhesions  form,  more  extensively  in  the 
deeper  glands  than  in  the  superficial.  These  soon  implicate  the  skin, 
and  discharge.  In  time  the  aft'ected  glands  m^at  together  and  become 
indistinguishable  individually  in  the  irregular  swelling,  and  one  after 
another  they  discharge,  often  through  different  openings.  These 
openings  continue  to  discharge  for  weeks  or  months.  The  presence 
of  an  open  sinus  with  a  swollen  mass  immediately  beneath  it  is  no 
proof  that  it  may  not  lead  to  an  abscess  in  glands  beneath  the  deep 
fascia.  The  inflammation  may  at  no  time  be  very  painful  or  tender 
excepting  during  exacerbations  or  the  tension  of  abscess  formation. 
The  general  health  may  be  aft"ected  very  little  if  any,  when  the 
disease  remains  local. 

Childhood  and  youth  are  the  periods  afflicted  with  gland  tuber- 
culosis. It  is  seldom  met  in  an  active  state  during  infanc}'  or  after 
puberty.  The  indolent  swelling  without  apparent  cause,  and,  if 
It  occurs,  the  caseation  and  suppuration  are  characteristic.  If  sup- 
puration does  not  take  place  the  condition  much  resembles  simple 
chronic  adenitis.  That,  however,  is  more  common  before  the  third 
year,  and  although  chronic  or  subacute,  its  progress  is  usually  more 
rapid  than  the  tubercular  form.  In  case  of  doubt  it  is  permissible 
to  use  the  tuberculin  test,  by  the  conjunctival,  the  cutaneous  or 
the  subcutaneous  method ;  or  to  excise  a  gland  for  examination. 
The  possibility  of  syphilis  should  be  borne  in  mind  and  an  initial 
lesion  searched  for  about  mouth  or  throat;  or  other  evidence  of  the 
disease  may  be  found  in  the  form  of  skin  eruptions ;  general  en- 
largement of  the  lymph-nodes ;  or  in  the  history,  or  by  examination 
of  the  blood. 

Lymphangioma  is  usually  though  not  always  congenital.  If 
it  grows  at  all  it  usually  grows  rapidly.  It  has  no  limiting  capsule, 
is  softer,  not  at  all  tender  unless  inflamed,  which  is  rare;  and  it 
presents  none  of  that  firm  distinct  nodulation  found  in  lymphadeni- 
tis before  suppuration. 

Sarcoma  may  successfully  invade  several  glands,  but  its  growth 
is  rapid.  Sarcoma,  unless  removed,  would  probably  reach  a  fatal 
termination  in  a  few  months. 

Carcinoma  of  glands  is  always  secondary  and  is  very  unusual 
in  childhood. 

In  leukemia  the  hyperplasia  is  general,  has  no  inflammatory 
symptoms,  and  presents  the  blood  findings  of  that  disease. 

In  pseudo-leukemia,  better  called  Hodgkin's  disease,  although 
the  swelling  often  begins  in  one  gland  or  group  of  glands,  it  soon  be- 
comes general.    The  glands  most  aft'ected  attain  large  size  without 


SURGICAL  DISEASES    OF    THE    LYMPHATICS  33^ 

tendency  to  suppurate  or  to  inflame ;  and  they  remain  elastic  and 
movable. 

Lymphoma  is  rare  at  any  age,  and  belongs  more  to  young  adult 
life  than  to  childhood.  Lymphoma  may  aiTect  more  than  one  gland, 
but  if  so  they  are  all  affected  equally  from  the  first  and  grow  at  the 
same  rate.  There  is  no  extension  to  other  glands.  It  is  movable, 
has  no  inflammatory  tenderness.  It  has  no  adhesions,  wdiich  is 
evidence  that  it  does  not  extend  beyond  its  own  capsule. 

Prognosis. — Dowd  reported  a  collection  of  309  cases  treated 
by  operation.  Of  these  65.4  per  cent,  were  apparently  cured  when 
seen  several  years  after  operation;  18.4  per  cent,  were  living,  but 
presented  evidence  of  tuberculosis,  either  local  or  general ;  16.2  per 
cent,  died  of  tuberculosis.  The  same  writer  quotes  Fisher's  table  of 
1273  cases,  which  showed  57.65  per  cent,  cures,  and  21.84  per  cent, 
of  local  recurrences,  while  13.5  per  cent,  died,  almost  entirely  from 
tuberculosis.  These  are  but  fair  presentations  of  the  general  belief  of 
the  profession,  that  although  cases  of  tubercular  lymphadenitis,  even 
without  operation,  do  occasionally  get  well,  the  disease  is  quite 
serious  and  one  should  make  a  guarded  prognosis. 

Treatment. — The  treatment  is  general  and  local.  The  general 
treatment  will  be  found  in  the  general  Section  on  Tuberculosis  in  a 
previous  chapter. 

In  the  local  treatment  attention  should  first  be  directed  to  pos- 
sible sources  of  infection  and  gates  of  entrance  and  the  introduction 
of  more  of  the  bacilli  prevented  if  possible.  It  is  to  be  remembered 
that  whatever  irritates  the  glands  renders  them  more  vulnerable 
to  infection  and  less  able  to  cope  with  it,  and  that  an  unhealthy 
condition  of  mucous  membrane  or  skin  in  the  field  drained  into 
the  gland  is  an  open  gateway.  Any  unhealthy  condition  of  the  oro- 
naso-pharynx,  ears  or  scalp  should  be  corrected ;  enlarged  tonsils, 
adenoids,  carious  teeth,  polypi,  hypertrophied  turbinated  bones  re- 
moved ;  catarrhs  cured ;  disease  of  the  eyes,  of  the  Eustachian  canals 
and  middle  ears  or  mastoids  treated ;  and  the  scalp  put  in  a  healthy 
condition.  As  to  the  local  application  to  the  skin  over  the  glands, 
one  does  not  know  that  any  of  them  accomplish  any  effect  upon  the 
tubercular  process.  Some  of  them  have  an  influence  upon  other  in- 
fections which  sometimes  complicate  the  tubercular  disease,  and  one 
has  used  ointments  of  guiacol,  of  iodide  of  lead,  and  of  mercury  in 
some  cases  with  apparent  benefit.  But  it  certainly  is  not  advisable 
to  apply  anything  that  irritates  or  excoriates  the  skin.  If  the  atten- 
tion of  parents  and  physicians  could  be  directed  away  from  local 
applications  over  the  glands  to  the  care  of  the  ears,  nose  and  throat 
much  more  good  would  be  accomplished. 

Of  the  treatment  by  injecting  the  glands  with  iodine,  carbolic 


334 


SURGICAL   DISEASES    OF   CHILDREN 


acid,  iodoform  emulsion,  acetic  acid,  and  the  like,  I  have  no  experi- 
ence. Chloride  of  zinc  I  have  tried  and  discontinued,  and  have  seen 
sodium  cacodylate  used  with  temporary  benefit.  There  is  danger 
that  attention  to  such  treatment,  even  if  harmless,  will  lead  to 
neglect  of  really  valuable  general  treatment,  and  to  delay  of  radical 
operation  until  the  most  favorable  time  is  past.  Curetting  is  done 
by  some,  but  it  appears  to  me  an  unsurgical  procedure  in  this  ana- 


FiG.   121.     Showing  the   natural  creases  of   the   skin   upon   the  neck; 
and  lines  of  incision  which  will  leave  least  conspicuous  scar. 

tomic  region  and  with  this  disease,  and  unsafe  both  on  account 
of  favoring  absorption  of  germs  and  general  infection,  and  of  pos- 
sible injury  to  important  structures.  The  general,  and  one  would 
think  sensible,  opinion  at  present  in  this  as  in  other  forms  of  sur- 
gical tuberculosis  is  to  avoid  half-way  measures,  but  if  some  opera- 
tion must  be  done  it  should  be  clean  and  complete.  If  the  constitu- 
tional treatment  does  not  avail,  but  the  glandular  swelling  continue? 
to  increase  month  after  month,  or  if  it  tends  to  suppurate,  or  the 
separate  glands  to  adhere  together,  operation  should  be  advised  and 
performed  before  extensive  adhesions  have  formed  and  the  peri- 


SURGICAL    DISEASES    OF    THE    LYMPHATICS  335 

glandular  tissues  become  inflamed.  An  operation  can  be  done,  even 
after  matting  of  the  tissues,  and  in  the  presence  of  suppuration  and 
sinuses,  but  it  is  far  more  difficult  and  dangerous,  and  causes  a  more 
extensive  wound  and  more  scarring  than  if  done  earlier.  If  done  at 
the  proper  time  there  is  more  likelihood  that  the  disease  can  be 
completely  eradicated ;  it  is  a  much  easier  and  safer  operation,  and 
the  comparatively  small  smooth  scar  or  scars  bear  no  resemblance 
to  those  resulting  after  no  operation. 

If  the  affected  glands  be  deeply  situated  the  operation  involves 
a  nice  dissection  and  the  surgeon  should  be  familiar  with  the  anat- 
omy of  the  triangles  of  the  neck.  External  appearances  are  often 
very  deceptive  in  these  cases ;  and  a  very  innocent-looking  sinus  or 
apparently  superficial  gland  may  lead  to  another  and  another  deeper 
and  deeper  and  farther  and  farther  until  an  entire  chain  of  a  dozen 
or  more  glands  are  removed,  and  one  has  been  led  into  very  inter- 
esting proximity  to  the  arteries,  veins  and  nerves  that  traverse  this 
region.  The  incision  should  be  large  enough,  for  here,  if  anywhere, 
one  should  not  cut  where  he  cannot  see.  Scarring  is  to  be  avoided 
by  the  direction  of  the  incision,  by  avoiding  the  tearing  of  tissues, 
by  nice  coaptation  when  it  comes  to  suturing  the  wound,  and  by 
every  effort  to  secure  union  by  first  intention.  A  careful  dissection 
also  avoids  shock,  and  protects  against  spread  of  infection  by  the 
accidental  opening  of  an  infected  gland.  In  selecting  the  line  of 
incision  one  should  avail  himself  of  the  studies  of  Langer  and  Kocher 
in  following  the  natural  cleavage  lines  of  the  skin.  In  the  neck 
these  run  transversely,  or  obliquely,  inclining  backward  and  upward. 
If  the  incision  is  made  in  this  direction  the  scar  will  not  stretch ; 
whereas,  with  a  longitudinal  incision  across  the  tension  of  the  skin, 
the  wound  tends  to  pull  open  and  the  resulting  scar  to  stretch.  This 
widening  of  the  longitudinal  scar,  however,  may  be  prevented,  as 
Mayo  has  shown,  by  careful  suturing  of  the  fascia.  Fig.  121  shows 
a  case  of  enlarged  glands  in  an  adult,  stained  with  iodine,  selected 
for  this  illustration  because  the  skin  creases  show  better  than  in  the 
child.  The  heavy  line  above  indicates  an  incision  which  usually 
gives  access  to  the  ordinary  case  where  the  upper  end  of  the  chain 
of  glands  is  implicated.  If  necessary  to  go  after  the  submaxillary 
nodes  also,  the  incision  could  be  made  higher,  prolonged  forward, 
keeping  at  least  a  finger  breadth  below  the  jaw  to  avoid  the  infra- 
maxillary  branch  of  the  cervico-facial  nerve.  The  line  below  is  a 
good  incision  for  the  lower  end  of  the  chain,  and  this  line  can  be 
prolonged  at  the  back  of  the  neck,  if  necessary.  But  where  the 
whole  chain  is  involved,  as  in  the  case  here  illustrated,  the  readiest 
access  could  be  obtained  by  an  incision  just  posterior  or  in  some 
cases  anterior  to  the  sterno-mastoid  and  parallel  to  it.  If  necessary 
this  can  be  prolonged  by  a  transverse  incision  extending  either  for- 


336  SURGICAL    DISEASES    OF    CHILDREN 

ward  or  backward  at  its  base  along  the  clavicle.  By  firmly  uniting 
the  fascia  in  closing  the  incision  the  stretching  of  the  scar  can 
to  a  great  degree  be  avoided.  The  eleventh  or  spinal  accessory 
nerve  must  be  spared  if  possible,  as  it  innervates  the  sterno-mastoid 
and  the  trapezius,  and  its  division  produces  paralysis  and  atrophy 
of  those  muscles,  one  or  both,  and  drooping  of  the  shoulder.  The 
phrenic  and  the  hypoglossal  may  be  injured,  but  are  more  easily 
avoided.  It  may  be  necessary  to  divide  the  sterno-mastoid  muscle. 
If  possible,  this  should  and  ordinarily  can  be  avoided.  If  cut,  the 
section  should  be  made  either  above  the  approach  or  below  the  exit 
of  the  spinal  accessory  nerve.  Before  closing  the  wound  the  severed 
ends  of  the  muscle  should  be  reunited.  Sharp  dissection  should  be 
employed  as  much  as  possible;  and  the  blunt  dissector  only  used 
when  tissues  separate  readily  without  tearing  or  dragging.  Bleed- 
ing points  should  be  promptly  arrested  with  pressure  forceps  and 
the  wound  kept  dry.  The  glands  should  not  be  seized  with  a  vol- 
sellum,  as  puncture  and  leakage  of  infective  material  is  probable. 
All  sinuses  should  be  followed  to  their  termini  and  all  diseased  tissue, 
whether  glandular  or  abscess  walls  in  cellular  tissue,  should  be 
removed.  All  diseased  skin  should  be  trimmed  oft,  and  sometimes 
in  long-standing  cases  old  scars  can  also  be  removed.  If  the  entire 
chain  is  to  be  excised,  it  is  usually  best  to  begin  below  and  work 
upward.  On  closing,  drainage  is  necessary,  as  there  is  more  than 
the  usual  discharge  from  a  wound  of  this  size  owing  to  Ivmph- 
orrhea  from  the  cut  lymphatic  vessels,  or  to  the  interference  with 
these  absorbent  channels,  A  strand  of  catgut  or  silkworm  gut 
makes  the  best  drain,  coming  out  at  the  lower  or  back  part  of  the 
wound,  or  through  a  counter-opening  below  the  collar  line.  IVIuscle 
or  fascia  is  closed  with  catgut ;  the  skin  usually  with  silkworm  gut. 
Some  use  catgut  subcutaneously.  English  surgeons  often  use  horse- 
hair. One  has  usually  used  subcutaneous  sutures  of  catgut  with  the 
greatest  satisfaction  and  almost  no  scar.  Ample  moist  dressings 
should  be  used,  and  changed  at  least  daily  for  several  davs,  oftener 
if  soiled,  or  if  dried.  It  is  well  to  steady  the  child's  head  with  sand- 
bags for  a  few  days. 

Dowd  ^  gives  an  instructive  showing  of  results  of  his  own  cases 
in  which  adults  and  children  are  compared  in  percentages. 

Over  20  years  of  age,  14  cases — 

Apparently  cured 57.2 

Filbert-sized  nodes,  diagnosis  doubtful 7.1 

Recurrent   nodes    21.3 

Phthisis    7. 1 

Tuberculosis  of  cranium 7.1 

^  Am.    Pract.    Surgery,    Bryant   and   Buck. 


SURGICAL    DISEASES    OF    THE    LYMPHATICS  337 
Under  20  years  of  age,  68  cases — 

Apparently   cured    77.9 

Filbert-sized  nodes,  diagnosis  doubtful 4.4 

Apparently  well  now,  but  have  had  recent  operations 8.8 

Recurrent  nodes 1.5 

Neck  well,  tubercular  coxitis 1.5 

Lupus    1.5 

Died  from  tuberculosis  of  the  spine   1.5 


SYPHILITIC  LYMPHADENITIS 

Syphilitic  lymphadenitis   is   rarely  met  in  children   and  yet  it 

should  be  borne  in  mind  as  a 
possibility.  The  field  drained 
by  the  swollen  gland  should 
be  searched  for  a  not  impossi- 
ble initial  lesion.  Or  it  ma}^ 
be  a  case  of  lues  hereditaria 
tarda,  and  Hutchinson's  teeth, 
deafness  without  otorrhea,  in- 
terstitial keratitis,  or  perios- 
titis, or  flattened  nose,  or 
the  scars  of  rhagades  may  be 
in  evidence.  The  history  may 
throw  some  light  upon  the 
diagnosis ;  or  failing  in  find- 
ing anything  else  decisive  the 
suspicion  may  be  confirmed 
or  dissipated  by  the  blood  test 
or  the  therapeutic  test. 

HODGKIN'S  DISEASE 

Hodgkin's  Disease  (Pseu- 
do-Ieukeniia,  Soft  LynipJiade- 
iioma,  Lympho-sarcouia,  Lym- 
phatic anemia,  Lymphade- 
noma,  Adenie). — This  is  a 
rare  disease  in  infancy  or 
childhood.  The  term  Hodg- 
kin's disease,  as  Cotton  re- 
marks, is  preferable  to  any  of 
the  numerous  names  that  have 


Fig.  122.  Hodgkin's  disease.  The 
affected  glands  in  the  neck  were 
removed  but  the  disease  subse- 
quently manifested  itself  in  the 
axillary  glands,  as  seen  in  Fig. 
123. 


been  proposed  as  substitutes,  because  it  is  not  misleading  in 
regard  to  its  etiology  or  pathology.  Its  etiology  has  not  yet 
been  determined,  but  its  behavior  leads  to  the  belief  that  it 
's  due  to  an  infection.     It  is  characterized  by  simple  hyperplasia 


338 


SURGICAL  DISEASES  OF  CHILDREN 


of  the  lymphatic  glands  and  the  appearance  of  lymphoid  growths 
in  the  enlarged  liver  and  spleen,  and  in  nearly  every  organ  but  the 
brain  and  spinal  cord.  The  enlargement  of  the  lymph-nodes  is 
often  first  noticed  upon  the  neck,  larger  upon  one  side,  and  later 
in  the  axillae  and  groins,  or  nearly  all  the  glands  in  the  body.  (See 
Figs.  122  and  123.)      Of  the  internal  glands  those  in  the  mediastinum 

and  retroperitoneum  are 
most  affected.  The  nodes 
which  first  begin  enlarging 
generally  attain  the  great- 
est size,  being  as  large  as 
walnuts  or  eggs.  They  are 
soft  but  not  fluctuating, 
sometimes  firmer ;  freely 
movable  early  in  the  case, 
later  being  more  in  mass 
and  attached  to  the  skin, 
but  not  implicating  it.  They 
grow  slowly  but  steadily, 
though  sometimes  stopping 
or  receding  temporarily 
under  treatment,  then  in- 
creasing again.  They  are 
painless  and  not  discol- 
ored. They  often  cause 
such  symptoms  as  cerebral 
congestion,  dyspnea,  cough 
and  dysphagia  from  pres- 
sure of  either  the  cervical 
or  the  internal  growths. 
Symptoms.  —  The  most 
marked  general  symptom  is  anemia.  The  changes  in  the  blood  are 
not  characteristic.  They  are  not  those  found  in  leukemia,  which  in 
some  of  its  features  the  disease  resembles.  The  number  of  white 
cells  is  usually  thought  not  invariably  below  normal ;  the  lymph- 
ocytes by  relative  count  are  increased;  no  increase  in  the  neutro- 
philes ;  reduction  in  the  number  of  the  red  cells  and  marked  re- 
duction in  hemoglobin. 

Diagnosis. — The  diagnosis  is  made  from  the  general  enlarge- 
ment of  the  glands,  with  anemia,  in  the  absence  of  leukemia. 

Treatment. — There  is  no  treatment  that  has  a  permanent  effect 
on  all  cases.  Arsenic  does  exert  a  considerable  control  over  many 
cases.  It  must  be  used  in  full  doses  and  persistently.  Cures  by 
arsenic  have  been  reported.  The  X-ray  has  a  marked  influence, 
though  probably  in  the  average  less  permanent  than  arsenic. 


Fig.  123.  Hodgkin's  bisease.  Same 
case  as  shown  in  Fig.  122.  The  glands 
of  the  neck  were  removed  by  the  au- 
thor, but  later  those  in  the  axilla  en- 
larged.    The  case  was  lost  sight  of. 


CHAPTER  XIII 

THE  HEAD  AND  BRAIN 

Anomalies  and  Deformities  of  the  Skull — Congenital 
Cranial  Meningocele  and  Encephalocele — Fractures  of 
the  Skull — Traumatic  Cranial  Meningocele  or  Trau- 
matic Cephalhydrocele — Pneumatocele  Cranii — Cephal- 
hematoma —  Microcephalus  —  Hydrocephalus  —  Lum- 
bar Puncture — Tapping  the  Ventricle  and  Permanent 
External  Drainage  —  Intracranial  Tumors  —  Cranio- 
cerebral Topography — Operations  upon  the  Cranium. 

ANOMALIES  AND  DEFORMITIES  OF  THE  SKULL 

The  pediatric  surgeon  should  have  a  knowledge  of  the  struc- 
tural peculiarities  of  the  head  of  the  infant  and  child.  This  knowl- 
edge should  include  not  only  normal  conditions,  and  the  changes  in- 
cident to  and  subsequent  to  birth/  but  certain  anomalies  and  de- 
formities, not  all  of  which  are  amenable  to  surgical  treatment,  but 
should  be  recognized  and  understood  in  diagnosis  and  prognosis. 
Plagiocephaly  (asymmetrical  skull),  acrocephaly,  pyrgocephaly 
(pointed,  tower-shaped  skull),  and  microcephaly,  may  be  detected 
on  sight,  and  their  associated  deformities  and  defects  sought. - 

Asymmetry  may  result  from  one-sided  pressure  in  utero,  con- 
stant lying  on  one  side,  defect  of  one  hemisphere,  birth  injuries, 
premature  unilateral  closure  of  sutures  ( ?)  ;  brain  tumors,  atrophy 
of  brain  ;  unilateral  atrophy  of  face,  torticollis ;  and  it  is  frequently 
associated  with  epilepsy,  rachitis  and  infantile  cerebral  palsies. 

Acrocephaly  is  regarded  as  a  stigma  of  degeneration,  or  possi- 
bly as  a  result  of  adenoid  vegetations ;  and  is  associated  with  idiocy, 
exophthalmos,  prognathos,  and  atrophy  of  optic  nerves.  In  mi- 
crocephaly the  skull  is  small  in  all  dimensions,  with  flattened 
forehead  and  occiput,  protruding  lower  jaw,  and  projecting  ears. 
It  is  a  mark  of  degeneration  and  hypoplasia,  or  results  from  fetal 
disease  of  brain,  and  constitutes  a  type  of  idiocy.  See  section  in 
this  chapter. 

^  See  Ballantyne,  "  Introduction  to  Disease  of  Infancy,"  chap.  II. 
2  See  Pflaundler  and  Schlossman,  vol.  I,  p.  34. 

3.39 


340  SURGICAL  DISEASES  OF  CHILDREN 

Under  macrocephaly  may  be  grouped  three  widely  different 
conditions  having  in  common  this  one  feature,  the  large  head. 
Hypertrophia  cerebri,  which  is  uncommon,  presents  a  protruding 
forehead  and  occiput,  with  f ontanelle  neither  bulging  nor  tense ; 
and  is  accompanied  by  severe  cerebral  symptoms.  Hydrocephalus 
will  be  described  in  a  separate  section  in  this  chapter.  Rachitic 
deformity  is  very  commonly  met.     For  description  see  page  103. 

The  natiform  skull,  sometimes  called  the  cross-shaped  head  or 
saddle-head,  or  bossed  head,  has  all  the  tuberosities  prominent 
with  the  region  of  the  lambdoid  suture  depressed.  This  deformity 
is  common  to  both  hereditary  lues  and  rickets  ;  but  the  rachitic  form 
does  not  present  until  the  second  year  or  during  the  second  six 
months  at  the  earliest,  and  has  soft  bones  and  a  large  fontanelle ; 
while  the  syphilitic  deformity  has  a  small  fontanelle  and  firmer 
bones,  excepting  in  cranio-tabes,  which  either  may  have.  (See  pages 
118,  213).  Cranio-tabes  may  also  be  due  to  osteo-genesis  im- 
perfecta or  to  obstetric  injurv.     See  also  Appendix   (56). 

CONGENITAL    CRANIAL    MENINGOCELE    AND    ENCEPHALO- 

CELE 

"  Meningocele  is  the  protrusion  of  some  part  of  the  membranes 
of  the  brain  through  a  gap  in  the  skull,  the  result  of  imperfect  ossi- 
fication." In  other  words,  it  is  a  hernia  of  the  meninges,  its  cavity 
being  continuous  with  the  subarachnoid  space,  covered  with  the 
dura,  and  with  the  scalp,  or  skin,  or  mucous  membrane,  according 
to  the  site  of  the  hernia.  The  covering  of  tlie  hernia  may  be  atten- 
uated and  consist  of  the  dura  only.  The  protrusion  is  present  at 
birth.  It  is  most  common  in  the  occipital  region,  the  gap  being  in 
the  supra-occipital  bone  between  its  centers  of  ossification.  Or  it 
may  protrude  between  the  frontal  and  nasal  bones  and  appear  at 
the  root  of  the  nose,  either  in  the  middle  line  or  in  an  angle  of  one 
of  the  orbits ;  or  in  the  spheno-ethmoidal  region  causing  a  hernia 
projecting  into  the  nasal  fossa  or  the  pharynx.  It  may  come  be- 
tween the  parietal  bones  or  escape  by  way  of  the  foramen  magnum. 
(See  Section  on  Congenital  Tumors  of  the  Spinal  and  Sacral  Re- 
gions). It  may  be  of  the  size  of  a  cherry  or  of  a  nut,  or  it  may  be 
nearly  or  quite  as  large  as  the  infant's  head.  The  tumor  usually 
contains  cerebro-spinal  fluid.  In  some  cases  a  portion  of  brain  is 
also  contained  in  the  sac,  in  which  variety  it  is  called  encephalocele. 
When  there  is  fluid  between  the  membranes  and  the  protruding 
brain  substance  it  is  termed  hydro-encephalo-meningocele.  Often 
the  condition  is  associated  with,  and  perhaps  results  from,  internal 
hydrocephalus,  and  the  protruding  portion  of  brain  contains  a  fluid- 
distended  cavity  or  cavities  connected  with  one  or  both  lateral  ven- 
tricles— hydrencephalocele. 

The  coverings  may  be  thick  or  very  thin,  may  be  lax  or  dis- 


THE    HEAD    AND     BRAIN  341 

tended  as  if  ready  to  burst,  and  become  more  tense  when  the  child 
cries.  The  tumor  may  appear  translucent,  in  which  case  the  contents 
are  fluid ;  or  opaque,  when  it  contains  brain  substance.  The  fluid 
contents  of  the  protrusion  may  be  partly  or  entirely  reduced  into 
the  cranium. 

The  swelling  may  increase  and  rupture,  or  ulceration  may  take 
place,  leading  to  escape  of  the  fluid.  In  either  case,  if  the  child  does 
not  die  in  convulsions,  meningitis  is  likely  to  ensue  and  prove  fatal. 
Occasionally  spontaneous  cure  has  resulted  after  rupture.  In  some 
cases  without  rupture  the  sac  may  shrink  and  shrivel ;  or  ossification 
may  close  the  opening  in  the  skull. 

Diagnosis. — In  some  instances  the  diagnosis  is  quite  easy,  the 
margins  of  the  cranial  opening  and  the  sac  containing  fluid  being 
quite  characteristic.  A  small  semi-solid  or  compressible  meningocele 
may  be  mistaken  for  a  nevus.  Nevus,  however,  is  usually  discol- 
ored. Or  it  may  be  considered  a  dermoid  cyst,  especially  if  located 
about  the  orbit — a  favorite  situation  for  small  dermoids.  But  the 
dermoid  is  not  compressible.  Meningocele  bears  some  resemblance 
to  cephalhematoma.  But  the  latter,  if  subperiosteal,  occupies  the 
situation  and  takes  the  shape  of  the  bone  upon  which  it  occurs,  or 
if  sub-aponeurotic  it  is  more  diffuse ;  and  in  either  form  more  flat- 
tened, with  no  tendency  to  pedunculation,  and  impossible  of  reduc- 
tion. 

There  is  some  resemblance  to  pneumatocele  cranii.  But  that  is 
situated  over  the  temporal  bone,  where  one  does  not  look  for  men- 
ingocele, and  contains  air  instead  of  fluid.  There  is  also  a  traumatic 
form  of  cranial  meningocele,  or  cephalhydrocele,  which  will  be  de- 
scribed in  another  section. 

Treatment. — Unless  the  tumor  is  very  tense  and  at  the  same 
time  thin-walled,  it  is  best  merely  to  protect  and  keep  it  under  obser- 
vation for  a  time  to  see  whether  it  tends  to  decrease  or  to  enlarge. 
If  the  opacity  and  perhaps  the  "  feel  "  of  the  tumor  make  it  apparent 
that  it  contains  a  portion  of  the  brain,  active  interference  is  contra- 
indicated,  unless  the  tumor  is  not  too  large  and  is  stationary.  If 
hydrocephalus  is  present  with  a  continuous  increase  of  fluid,  opera- 
tion will  prove  futile.  If  the  opening  in  the  skull  is  not  too  large,  in 
other  words,  if  the  tumor  is  somewhat  pedunculated  and  its  cover- 
ings sufficiently  thick  and  healthy  to  produce  flaps,  ablation  of  the 
protrusion  may  be  attempted,  any  projecting  portion  of  the  brain 
being  removed.  An  attempt  should  first  be  made  to  reduce  the 
amount  of  fluid  in  the  sac.  Sudden  opening  and  emptying  of  a 
tense  sac  may  lead  to  convulsions  and  death  at  once.  Even  aspira- 
tion will  sometimes  cause  convulsions,  and  may,  of  course,  but  should 
not  if  done  under  precautions,  cause  meningitis.  Pressure  has  been 
advised  for  reducing  the  size  of  the  sac.     But  pressure  alone  only 


342  SURGICAL    DISEASES    OF    CHILDREN 

forces  the  fluid  into  the  skull,  and  may  give  rise  to  symptoms  of 
intracranial  tension.  I  have  found  that  the  use  of  glycerine,  applied 
upon  a  saturated  compress  over  the  tumor  and  held  in  place  by  an 
elastic  bandage,  will,  by  exosmosis,  abstract  some  of  the  fluid  and 
shrivel  the  sac  without  perforating  it.  Those  thin-walled,  distended 
sacs,  threatening  to  burst,  become  thicker  under  the  use  of  glycerine. 
Later,  then,  if  the  conditions  warrant,  with  less  tension  and  a  smaller 
and  flaccid  sac,  excision  may  be  done.  In  those  cases  in  which  by 
later  ossification  the  opening  in  the  skull  has  closed  and  cut  off  the 
meningocele  from  the  cranial  cavity,  there  need  be  no  hesitation 
about  its  removal. 

If  removal  is  attempted,  the  operation  is  much  the  same  as  that 
for  spina  bifida  without  osteoplasty.  The  skin  is  dissected  from  the 
tumor,  leaving  the  membranes.  These,  if  not  too  bulky,  may  be 
folded  up  within  the  skin  flaps ;  or  the  sac  may  be  sutured  and  a  por- 
tion cut  off  and  the  skin  flaps  closed  over  this  suture  line.  Or  ^^lor- 
ton's  fluid  may  be  injected  in  the  same  manner  as  is  used  for  spina 
bifida  iq.  z\).  This  plan  is  out  of  favor.  Or  Morton's  fluid  or 
similar  preparation  may  be  injected  into  the  walls  of  the  sac  without 
penetrating  its  interior,  with  a  view  to  changing  their  character  and 
causing  them  to  thicken  and  contract. 

FRACTURES    OF    THE    SKULL 

In  no  part  of  the  anatomy  does  greater  change  take  place  from 
infancy  to  adult  life  than  in  the  skuh.  At  first  composed  of  eight 
separate  segments  of  partly  ossified  membrane  and  cartilage  loosely 
held  together  and  capable  of  being  molded  into  an  entirely  different 
shape,  it  passes  through  various  stages  in  which  plasticity  yields  to 
firmness  and  elasticity  to  hardness  until  it  finally  resembles  a  ce- 
mented casket  of  one  piece  almost  as  hard  and  brittle  as  porcelain. 
The  brain  and  membranes  which  it  contains  undergo  quite  as  re- 
markable changes  in  consistency  and  in  development  of  structure. 
It  is  not  strange,  then,  that  the  eft'ects  of  external  violence  both  upon 
the  skull  itself  and  upon  its  contents  should  be  widely  different  in 
the  young  child  from  similar  injuries  in  the  adult,  and  that  these 
differences  vary  less  and  less  from  infancy  on  until  the  adult  type  is 
reached.  It  is  obvious  why.  with  the  comparatively  soft  and  yielding 
bones  of  the  young  child,  force  is  not  transmitted  to  more  distant 
parts  sufficiently  to  overcome  cohesion,  and  both  the  "  bursting  frac- 
ture "  and  the  "  bending  fracture  "  are  comparatively  rare  ;  why  ex- 
tensive Assuring  seldom  occurs,  and  why  the  elaborated  laws  of 
"  fracture  by  contrecoup  "  are  set  at  naught.  There  is  a  tendency 
for  the  bones  to  bend  rather  than  to  break,  and  for  the  part  receiving 
the  force  to  bear  the  brunt  of  it  rather  than  to  transmit  it,  and  for  the 
contents  of  the  cranium  to  yield  to  pressure  rather  than  to  resist  it  or 


THE    HEAD    AND    BRAIN  343 

be  disturbed  by  it ;  while  the  blood-vessels  are  more  elastic  and  less 
friable,  and  the  brain  structure  less  highly  organized  and  less  affected 
organically  by  changes  in  its  circulation.  Thus  one  has  seen  a  young 
child  tumble  from  a  second  story  window  and  perceptibly  flatten  its 
cranium  upon  the  sidewalk,  and  after  temporary  concussion  be  none 
the  worse  for  its  experience.  However,  the  dura  mater  is  very 
closely  adherent  in  a  child,  and  if  an  area  of  bone  be  fractured  and 
driven  in,  it  is  more  apt  to  lacerate  and  carry  with  it  this  fibrous 
membrane,  and  to  injure  the  brain,  than  would  a  similar  fracture 
with  depression  in  an  adult.  Splintering  of  bone  is  less  common  than 
in  adults,  and  splintering  of  the  inner  table  is  quite  rare.  Depres- 
sion or  bending  in  of  a  large  surface  without  fracture  or  with  a 
kind  of  greenstick  fracture  is  more  common.  Owing  to  softness  of 
the  skull  and  the  loose  attachment  of  the  scalp,  considerable  injuries 
of  the  bone  may  occur  with  very  little  evidence  of  it  upon  the  sur- 
face. Children  not  uncommonly  recover  from  fracture  of  the  base 
of  the  skull.  One  has  seen  this  in  undoubted  cases.  Also  recovery 
from  traumatic  meningitis,  from  which  it  did  not  seem  possible  that 
an  adult  could  have  recovered.  But  as  a  rule,  traumatic  meningitis 
is  less  apt  to  occur  in  children.  In  punctured  wounds  of  the  skull, 
which  are  more  easily  made  in  children  on  account  of  the  thinness 
of  the  cranium,  no  harm  may  result  if  septic  matter  be  not  intro- 
duced with  the  entering  point. 

Diagnosis  and  Treatment  of  ordinary  fractures  of  the  skull  are 
based  upon  the  same  general  principles  as  obtain  in  similar  cases 
in  adults,  excepting  that  with  children  there  is  less  call  for  active 
interference.  Quietude,  open  bowels,  bromides,  with  careful  anti- 
sepsis, and  cold  to  the  head  are  the  best  line  of  treatment  in  most 
cases.  A  word  of  caution  may  be  necessary  concerning  the  appli- 
cation of  cold.  Serious  depression  may  be  caused  by  placing  a 
child's  head  in  cold  storage,  packed  in  icebags,  as  one  sometimes  sees 
done.  C24) 

PROLAPSUS  AND  HERNIA  CEREBRI 

Prevention  is  easier  than  cure.  Compound  fracture  of  the 
skull  or  a  trephine  or  other  surgical  opening  of  the  skull,  with  pro- 
trusion of  a  portion  of  th'e  brain  covered  by  membranes  (hernia 
cerebri),  or  of  the  brain  substance  without  membranous  covering, 
(prolapsus  of  the  brain),  are  very  troublesome  and  dangerous  condi- 
tions. The  protrusion  may  be  caused  by  hemorrhage  or  result  from 
brain  abscess  or  from  imbibition  of  serous  flow  from  the  wound. 
Suppuration  or  gangrene  or  superabundant  granulations  may  make 
the  brain  tissue  unrecognizable.  It  may  appear  to  be  a  new  growth, 
or  a  sloughing  tumor.  Abscess  should  be  evacuated.  A  gangrenous 
portion  may  separate  spontaneously.    Fungous  granular  tissue  should 


344  SURGICAL   DISEASES    OF    CHILDREN 

be  removed  if  it  is  protruding  and  preventing  closure.  The  pro- 
trusion should  be  prevented  if  possible,  or  treated  if  it  occurs,  by 
closing  the  soft  parts  over  the  gap  in  the  skull  and  the  use  of  anti- 
septic dressings  w^ith  sufficient  pressure  to  support  the  tissues.  A 
gutta-percha  plate  fitted  to  the  gap  may  be  of  assistance. 

TRAUMATIC  CRANIAL  MENINGOCELE  OR  TRAUMATIC 
CEPHALHYDROCELE 

This  condition  is  peculiar  to  childhood.  It  results  from  frac- 
ture of  the  skull  with  sufficient  intracranial  injury  to  allow  the  es- 
cape of  cerebro-spinal  fluid  beneath  the  aponeurosis  of  the  occipito- 
frontalis.  The  condition  may  not  appear  immediately  after  the 
injury  but  some  weeks  later.  Some  consider  the  inner  hernial  cov- 
ering to  be  the  cerebral  meninges  which  protrude  through  the  frac- 
ture. The  cerebro-spinal  fluid  is  probably  augmented  by  irritation 
set  up  by  the  injury.  The  pressure  of  the  tumor  produces  partial 
absorption  of  the  bones  at  the  margins  of  the  opening.  Pulsation 
may  or  may  not  be  present. 

Diagnosis. — The  diagnosis  is  made  from  the  history  of  injury 
with  subsequent  gradual  appearance  of  a  fluctuating  tumor,  which 
tends  to  increase  in  size.  A  hematoma  occurs  promptly  after  injury, 
and  having  soon  attained  its  full  size,  tends  to  diminish.  If  there 
is  doubt,  aseptic  aspiration  will  discover  whether  the  tumor  is  filled 
with  blood  or  with  cerebro-spinal  fluid. 

Prognosis. — Prognosis  is  uncertain.  Many  cases  recover,  but 
some  die,  usually  of  meningitis.  The  prognosis  is  best  in  cases  hav- 
ing a  small  cranial  opening. 

Treatment. — The  treatment  should  be  very  cautious.  Active 
open  interference  is  not  demanded,  nor,  in  most  cases,  permissible. 
Palliative  treatment  with  support  to  the  tumor  offers  as  good  a  pros- 
pect as  any.  If  tension  is  great  and  tapping  is  resorted  to  it  should 
be  done  with  the  strictest  antiseptic  methods  and  the  tumor  entered 
through  the  unaffected  tissues  at  its  base. 

PNEUMATOCELE  CRANII 

This  is  a  rare  and  peculiar  tumor  appearing  in  the  temporal 
region  and  occiput  or  over  the  frontal  sinus  or  one  of  the  orbits. 
The  majority  of  the  reported  cases  have  been  in  adults ;  yet  it  is  said 
to  occur  sometimes  in  children  or  even  congenitally,  although,  con- 
sidering the  development  of  the  sinuses  and  of  the  mastoid  portion 
of  the  temporal  bone,  its  occurrence  in  childhood  must  be  extremely 
rare.  The  tumor  is  produced  by  air  which  dissects  up  the  pericra- 
nium, so  that  one  wall  of  the  tumor  is  lined  by  the  pericranium  and 
the  other  is  the  cranial  bone.  The  tumor  is  circumscribed,  painless, 
disappears  on  pressure,  but  reappears.  Forcible  expiration  or  infla- 
tion with  the  Pollitzer  bag  renders  it  more  tense.  It  is  tympanitic 
on  percussion.     The  air  lifts  the  pericranium  and  escapes  into  the 


THE    HEAD    AND     BRAIN  345 

space  beneath,  but  is  prevented  from  returning  so  readily  by  valve- 
like action  of  the  pericranium  over  the  orifice  of  entrance.  Con- 
fined in  this  cavity  of  living  tissues  a  part  of  the  oxygen  is  absorbed 
from  the  air,  while  the  nitrogen  remains  and  carbonic  acid  gas  is 
added ;  so  that  analysis  of  the  gaseous  contents  of  a  pneumatocele 
shows  87  per  cent,  of  nitrogen,  10  per  cent,  of  oxygen,  and  2  per 
cent,  of  carbon  dioxid.  This  finding  misled  Chevance  de  Wassy 
and  other  earlier  observers  into  the  opinion  that  the  contents  of  the 
tumor  was  not  air.  After  the  tumor  continues  for  a  week  or  two 
the  pericranium  begins  the  proliferation  of  new  bony  tissue  in  a 
ridge  around  the  margins  of  the  tumor  similar  to  that  found  in 
cephalhematoma,  and  shreds  of  adherent  tissue  in  the  cavity  be- 
come bony  spiculte  which  crush  as  the  tumor  is  manipulated.  In 
some  cases  there  is  a  history  of  trauma,  in  others  of  mflammation 
of  the  ear  or  sinus,  but  in  many  no  cause  is  assigned.  (For  a  synop- 
sis of  the  literature  see  article  by  Wallace,  Jour.  A.  M.  A.,  May  6, 

19050 

Treatuicnt. — It  has  been  recommended  to  obliterate  the  cavity 
by  injecting  tincture  of  iodine  to  excite  inflammatory  adhesion  of  its 
walls.  A  better  method  is  to  incise  the  tumor  and  pack  it ;  or  if 
granulations  have  formed  to  compress  it  so  that  the  surfaces  will 
adhere. 

CEPHALHEMATOMA 

Cephalhematoma  or  blood  tumor  of  the  head  occurs  at  the 
time  of  birth  from  injury  to  blood  vessels,  or  to  this  combined  with 
the  venous  congestion  due  to  asphyxia  and  that  peculiar  state  of  the 
blood  of  the  new-born  which  favors  hemorrhage.  Cephalhematoma 
is  sometimes  divided  into  external  and  internal,  the  internal  being 
defined  as  a  blood  tumor  within  the  cranium,  either  sub-cranial 
or  sub-arachnoidal.  But  the  conditions  of  an  external  and  an  in- 
ternal hemorrhage,  although  similar  in  origin,  are  so  different  in 
their  clinical  aspects  that  it  seems  unwise  to  classify  them  together. 
But  it  is  wise  to  remember  that  where  cranial  injury  has  produced 
hemorrhage  externally,  internal  hemorrhage  also  may  have  taken 
place,  and  to  look  for  any  evidence  of  it.  It  has  been  asserted  that 
the  edges  of  foramina,  particularly  those  situated  near  the  inter- 
parietal suture  or  the  posterior  fontanel,  are  instrumental  in  wound- 
ing the  vessels  they  transmit ;  and  also  that  intracranial  and  extra- 
cranial collections  of  blood  may  communicate  through  the  fora- 
mina. 

The  second  variety  is  less  frequently  met.  In  this  the  hemor- 
rhage takes  place  between  the  aponeurosis  of  the  occipito-frontalis 
and  the  pericranium,  and  may  occur  upon  any  part  of  the  head 
covered  by  this  aponeurosis.  Very  rarely  indeed  there  may  be  a 
hemorrhage  between  the  scalp  and  the  pericranium.  In  either  case 
the  tumor  is  generally  not  present  at  birth,  but  appears  perhaps  a 


346 


SURGICAL   DISEASES    OF   CHILDREN 


few  hours  later,  or  may  not  be  discovered  until  next  day.  It  is 
often  located  upon  the  presenting  part,  but  not  invariably  so.  In 
size  it  varies  from  that  of  an  egg  to  that  of  an  apple,  but  hemi- 
spherical or  flattened.  (See  Fig.  124.)  The  sub-periosteal  variety 
never  gets  larger  than  the  bone  upon  which  it  occurs  and  its  outline 
is  defined  by  the  marginal  attachment  of  the  periosteum.  The  sub- 
aponeurotic variety  is  not  limited  in  situation,  size. or  shape  by 
any  suture  lines.  There  is  no  heat,  tenderness,  nor  discoloration. 
The  tumor  is  tense,  but  fluctuation  may  usually  be  detected ;  and  it  is 
irreducible.  The  tumor  may  continue  to  increase  in  size  for  several 
hours  and  even   for  a  day   or  two.     It  then  becomes   stationary 


Fig.    124.      Cephalhematoma. 

and  later  slowly  diminishes.  With  the  sub-periosteal  variety  the 
periosteum  soon  attempts  the  formation  of  bone  upon  its  under  sur- 
face, so  that  if  examined  when  the  babe  is  ten  days  or  two  weeks 
old  a  crater-like  margin  may  be  felt  all  round  the  tumor.  This  with 
the  fluctuating  center  gives  much  the  same  impression  to  the  touch 
as  a  hiatus  of  the  skull  with  the  meninges  protruding.  When  the 
thin  layer  of  bone  has  extended  over  the  whole  surface,  pressure 
may  produce  an  "  eggshell  crackling "  on  palpation.  In  a  few 
weeks  or  a  month  or  two  the  tumor  usually  disappears.  Not  quite 
all  the  effused  blood  may  be  reabsorbed,  but  the  new  layer  of  bone 
formed  beneath  the  periosteum  seals  it  in;  and,  if  examined  years 
after,  nothing  remains  but  a  slightly  thickened  portion  of  skull  which 
has  a  thin  stratum  of  the  coloring  matter  of  blood-cells  near  its  outer 
surface,  covered  with  a  layer  of  bone.  Occasionally  a  cephalhema- 
toma may  fail  to  absorb  or  may  become  infected  and  suppurate. 

Diagnosis. — The  diagnosis  is  usually  easy  if  one  remembers 
the  possibility  of  this  condition.  The  most  common  tumefaction 
upon  the  head  of  the  new-born  is  of  course  the  caput  succedaneum. 


THE   HEAD    AND    BRAIN  347' 

But  that  is  present  at  birth,  is  firm  and  doughy,  and  tends  to  disap- 
pear in  a  day  or  two.  Meningocele  bears  some  resemblance ;  but  it 
is  located  at  an  opening  or  over  a  suture  instead  of  upon  a  bone, 
pulsates  like  the  brain,  increases  when  the  babe  cries,  and  is  partially 
reducible,  giving  rise  usually  to  nervous  symptoms  when  pressed 
upon. 

Treatment. — Judicious  letting  alone  is  the  best  treatment  for 
the  great  majority  of  these  blood  tumors.  It  is  well  enough  to  use 
light  pressure  and  perhaps  an  evaporating  lotion.  Cutting  down  to 
find  the  bleeding  pomt  is  not  called  for.  Nor  is  aspiration  of  the 
effused  blood,  nor  opening  and  turning  out  the  clot.  These  would 
only  add  a  risk  of  sepsis ;  for  in  all  probability  the  blood  will  be  taken 
care  of  in  time,  as  before  described.  Symptoms  of  compression 
require  exploration,  probably  operation.  If  suppuration  should 
occur  there  is  no  choice  but  to  incise  promptly,  evacuate,  irrigate 
and  drain. 

MICROCEPHALUS 

Microcephalus  is  a  premature  arrest  of  development  of  the 
brain  and  skull,  usually  accompanied  by  idiocy  and  cerebral  paralysis 
in  varying  degrees.    The  primary  cause  of  this  arrest  is  unknown. 

On  the  supposition  that  premature  ossification  of  the  su- 
tures and  closure  of  the  fontanelles  stopped  the  growth  of  the  brain, 
operations  were  devised  by  Lane,  Fuller,  Lannelongue  and  others, 
to  open  the  cranium  in  such  a  manner  as  to  allow  the  brain  to  ex- 
pand and  have  room  to  grow.  This  is  generally  called  Lannelongue's 
operation  or  craniectomy.  It  consists  in  the  removal  of  a  strip  of 
the  skull  from  one  or  both  sides,  parallel  with  and  an  inch  or  more 
away  from  the  saggital  suture.  The  portion  removed  might  be 
half  an  inch  wide  and  four  or  five  inches  long;  or  the  strips  upon 
the  two  sides  were  connected,  making  the  removed  portion  H 
shaped ;  or  the  opening  was  V  or  Y  or  inverted  U  or  O  shaped,  as 
devised  by  dift'erent  operators.  The  periosteum  was  also  removed, 
to  avoid  or  delay  reproduction  of  bone ;  but  the  dura  not  opened. 
The  hopelessness  of  the  condition  possibly  justified  these  experi- 
mental operations,  but  they  were  based  upon  an  unproven  supposi- 
tion and  ended  in  failure.  Soon  after  the  introduction  of  this  opera- 
tion, the  writer  had  a  long  conference  upon  the  subject  with  the  late 
Dr.  G.  A.  Doren.^  After  reviewing  carefully  the  pathology  of  this 
class  of  cases  we  concluded  that  the  hopes  held  out  were  unfounded; 
there  was  no  reasonable  prospect  that  the  operation  could  succeed 
in  congenital  microcephalus,  and  I  refrained  from  performing  it  or 
advising  it.  This  opinion  has  been  amply  justified  by  the  sequel. 
Craniectomy  is  no  longer  used  or  recommended  for  congenital  mi- 
crocephalic idiocy. 

1  Superintendent    of   the    Ohio    State    Institution    for    Feeble    Minded 
Children. 


348  SURGICAL   DISEASES    OF   CHILDREN 

HYDROCEPHALUS    (WATER   ON  THE   BRAIN) 

Hydrocephalus  consists  in  an  abnormal  accumulation  of  cerebro- 
spinal or  serous  fluid  within  the  cranium.  There  are  two  principal 
varieties — acute  hydrocephalus  and  chronic  hydrocephalus. 

Acute  Hydrocephalus  is  merely  one  of  the  symptoms  of 
meningitis,  usually  of  basilar  meningitis,  which  is  almost  always  a 
tubercular  disease.  All  forms  of  acute  meningitis  are  accompanied 
by  a  certain  extra  amount  of  serous  exudation  into  the  ventricles, 
but  it  is  only  in  the  basilar  form  of  which  the  tubercular  is  the 
type  that  the  quantity  is  large  and  gives  prominent  symptoms  and 
characterizes  the  disease. 

Chronic  Hydrocephalus  is  in  two  distinct  varieties,  hydro- 
cephalus externus  or  meningeus,  and  chronic  hydrocephalus  internus 
or  ventriculorum. 

Chronic  Hydrocephalus  Externus  (H.  Meningeus)  is  a  rare 
condition,  usually  found  in  connection  with  malformation  of  the 
brain  or  prenatal  disease,  or  resulting  from  pachymeningitis  or 
hemorrhage  either  before  or  after  birth.  The  two  forms  may  be 
combined.  That  is,  with  external  hydrocephalus  and  atrophy  of 
both  hemispheres,  one  of  the  ventricles  may  be  somewhat  dilated. 
Pachymeningitis  may  also  give  rise  to  a  somewhat  allied  condition 
called  hygromata  of  the  dura,  consisting  of  encapsulated  collections 
of  fluid.  The  external  form  seldom  gives  rise  to  the  expansion  of  the 
skull,  as  seen  in  the  internal  variety. 

Chronic  Hydrocephalus  Internus  (H.  Ventriculorum). — This 
is  the  commonest  variety  and  also  the  one  most  important  from  the 
surgical  standpoint.  It  may  occur  as  an  accompaniment  of  chronic 
basilar  meningitis  precisely  like  the  acute  form  but  running  a 
chronic  course,  or  it  may  be  caused  by  the  irritation  of  tumor 
growth.  But  neither  meningitis,  simple  or  tubercular,  nor  brain 
tumor  may  be  present,  and  yet  hydrocephalus  of  the  internal  variety 
may  develop,  either  before  or  at  some  time  after  birth.  Heredity 
has,  of  course,  been  considered  as  a  cause.  Although  many  instances 
have  been  reported  of  more  than  one  case  of  hydrocephalus  being 
born  or  developing  in  the  same  family,  this  does  not  occur  with 
anything  like  the  frequency  of  rickets,  for  example,  and  bears  no 
comparison  with  syphilis,  tuberculosis,  or  many  other  diseases  in 
which  either  the  disease  or  a  predisposition  to  the  disease  is  known 
to  be  inheritable.  In  my  own  cases  I  have  never  been  able  to  get 
a  history  of  the  disease  occurring  in  previous  generations  of  the 
same  family  or  its  branches.  Syphilis  undoubtedly  is  associated 
with  some  cases,  but  there  are  others  in  which  no  luetic  taint  can 
be  traced,  and  which  will  not  respond  to  syphilitic  treatment.  Rickets 
is   constantly  mentioned   in   connection   with  hydrocephalus,    Park 


THE   HEAD   AND   BRAIN  349 

and  other  authors  stating  that  it  is  "  most  common  in  rachitic  chil- 
dren," and  placing"  "  rachitic  curvatures  of  the  long  bones  "  among 
the  symptoms.  In  my  own  experience  there  has  never  seemed  to 
be  anything  more  than  an  occasional  or  accidental  association  of 
these  diseases  in  the  same  patient.  There  is  no  constant  or  even 
frequent  association,  and  the  two  appear  to  me  essentially  different. 
Hydrocephalus  is  not  more  prevalent  at  the  period  when  rickets 
is  most  prevalent,  and  the  treatment  of  one  has  no  curative  effect 
upon  the  other.  It  is  true  that  other  deformities  not  infrequently 
accompany  the  disease  when  congenital,  but  they  are  usually  such 
as  show  a  direct  relationship  to  the  dropsical  condition  of  the  brain 
coverings,  for  instance,  cranial  meningocele  or  spina  bifida,  or  the 


Fig.   125.     Hydrocephalus  internus.     Autopsy  on  same  case  is  shown  m 

Fig.  128. 

results  of  maldeveloped  nerve  centers,  producing  paralysis  of  blad- 
der and  rectum  or  lower  extremities,  or  clubfoot,  and  the  like. 
One  could  not  quite  so  confidently  deny  tuberculosis  a  possible  causa- 
tive relationship,  even  when  tubercule  is  not  found. 

Operations  for  spina  bifida  or  meningocele,  or  treatment  of 
these  conditions  by  pressure  are  sometimes  followed  by  accumula- 
tion of  the  fluid  within  the  cranium. 

Chronic  ependymitis  is  given  as  a  cause,  but  that  does  not  ex- 
plain what  inflames  the  ependyma.  The  syphilitic  virus  might,  but 
what  of  the  simple"  ca'^es?  In  some  cases  it  appears  as  though  in- 
flammatory or  developmental  causes  had  closed  the  foramina  of 
Munro  and  the  aqueduct  of  Sylvius  or  the  foramen  of  Majendie, 
leading  to  accumulation  of  the  fluid  in  the  ventricles. 

Pathologic  Anatomy. — Chronic  hydrocephalus  may  present  a 
skull  of  ordinary  or  less  than  ordinary  size.  But  in  the  great  ma- 
jority of  cases  the  cranium  is  enlarged.  In  the  congenital  cases  and 
those  occurring  in  the  first  few  months  of  life  the  sutures  and 
fontanelles  are  wide  and  occasionally  there  are  portions  of  the  skull 


350  SURGICAL  DISEASES    OF   CHILDREN 

other  than  the  fontanelles  or  sutures  where  bone  is  absent.  In  cases 
that  are  very  chronic  and  survive  five  or  six  years,  ossification  has 
usually  taken  place.  On  opening  the  skull  and  membranes  one 
finds  the  brain  showing  very  shallow  convolutions,  the  cortex  being 
thinned  by  the  distension  of  the  ventricles.  In  the  case  shown  in 
Figs.  125  and  128  it  was  scarcely  an  eighth  of  an  inch  in  thick- 
ness, and  no  convolutions  were  apparent,  nor  could  one  distinguish 
between  white  and  gray  matter.  All  the  openings  between  the  ven- 
tricles are  enlarged.  In  cases  dying  after  operation,  the  ependyma 
is  found  inflamed.  The  fluid  contained  in  the  enlarged  vetricular 
cavities  is  much  like  cerebro-spinal  fluid,  excepting  that  in  a  few 
cases  there  are  traces  of  sugar,  in  the  infected  cases  pus,  and  fol- 
lowing inflammation  more  albumin  than  normal.     The  amount  of 


Fig.   126.     Fetal  hydrocephalus.     Craniotomy  at  term  by  Dr.  A.  J.  Skeel. 

fluid  varies  in  different  cases  from  ounces  to  pints.    When  it  is  re- 
moved the  brain  collapses  like  a  cyst. 

Symptoms  and  Diagnosis. — The  disease  may  originate  during 
fetal  life  and  death  take  place  in  utero,  or  at  birth  the  head  may  be 
so  enlarged  as  to  preclude  birth  alive.  The  obstetrician  discovering 
the  condition  does  craniotomy  or  cephalotripsy.  Four  times  in  my 
early  practice  I  had  this  unpleasant  duty  to  perform.  Fig.  126 
shows  such  a  case.  Or  the  condition  may  come  on  in  a  few  months 
after  birth  or  later  in  infancy.  The  head  is  observed  to  be  growing 
too  rapidly.  Boas  states  the  average  head  in  the  normal  boy  at 
birth  to  be  13.9  inches  (35.5  cen.),  at  six  months  17  inches  (43.5 
cen.),  at  twelve  months  18  inches  (45.9  cen.),  at  eighteen  months 
18.5  inches  (47.1  cen.).  An  average  example  of  hydrocephalic 
enlargement  is  shown  in  Fig.  125.  At  eighteen  months  of  age  the 
head  measured  24^  inches,  and  19^  inches  over  the  vertex  from 
ear  canal  to  ear  canal;  and   18  inches  from  occiput  to  glabella. 


THE   HEAD    AND   BRAIN 


351 


Holt  mentions  one  of  his  cases  which  measured  at  four  months 
24!^  inches  in  circumference.  These  two  cases  by  comparison  show 
the  well-known  fact  that  the  rate  of  growth  of  the  head  varies 
greatly  in  different  cases,  it  may  be  from  an  inch  to  two  or  three 
inches  a  month.  The  shape  of  the  head  varies  also,  but  is  gen- 
erally quite  globular  from  the  ears  up,  or,  taken  together  with  the 
small  face,  it  is  pear-shaped  or  pyramidal,  pointed  at  the  chin,  flat 
at  the  sides  and  expanded  above.  Fig.  127,  aged  four  months, 
shows  the  globular  head.  The  forehead  is  extremely  high  and 
prominent.     Thus  it  is  very  different  from  the  rachitic  head,  which 


Fig.  127.  Typical  chronic  hydrocephalus  in  infancy.  Note  the  globular 
cranium.  The  head  above  the  ear  canals  forms  nearly  three-quarters 
of  a  circle.  The  face  is  pointed  at  the  chin,  making  the  face  and 
cranium  together  pear-shaped.  The  position  of  the  eyeballs  in  their 
sockets   is   characteristic. 


is  cubical,  flat  at  top  and  sides.  The  hydrocephalic  case  has  bulging 
fontanelles  and  open  sutures.  Fluctuation  can  often  be  obtained. 
The  scalp  appears  tightly  stretched,  the  hair  is  usually  scanty,  and 
veins  are  large  and  prominent.  The  eyes  are  pushed  downward  and 
somewhat  forward  by  the  pressure  of  the  fluid  above  and  behind 
their  orbits,  so  that  the  white  shows  plainly  below  the  upper  lid. 
The  pupils  contract  evenly  to  light,  but  in  some  cases  become  in- 
sensitive and  dilated.  Nystagmus  and  squint  and  irregular  rolling 
of  the  eyes  are  common.  Mental  development  ceases  or  deteriorates, 
according  to  the  severity  of  the  case.  The  mental  state,  including 
the  special  senses,  is  dull.  The  motor  control  also  is  affected, 
producing  exaggerated  reflexes,  partial  paralysis,  which  is  often 
spastic.  Cor^vulsions  occur  in  some  cases,  sometimes  marking 
intercurrent  attacks  of  meningitis,  which  are  repeated  at  intervals 
of  weeks  or  months.  The  weak  state,  the  incoordination  of  muscles, 
and  the  size  and  weight  of  the  head  prevent  it  being  carried  up- 
right. Some  of  these  babies  cannot  hold  up  the  head  at  all.  Others 
can  by  the  second  or  third  year,  and  can  walk  at  five  or  six,  but  re- 
tain the  mental  condition  of  infancy.     Thus  there  are  all  grades 


352  SURGICAL   DISEASES    OF   CHILDREN 

of  seventy,  both  as  regards  the  growth  of  the  head,  the  impairment 
of  brain  and  consequently  mind,  special  senses,  and  motor  control. 
There  may  be  complete  idiocy  or  only  slight  impairment.  It  is 
astonishing  that  the  brain  can  perform  any  function  while  so  com- 
pressed, distorted  and  atrophied.  A  fractional  part  of  this  com- 
pression, if  coming  suddenly,  would  produce  coma  and  death,  but 
it  augments  so  slowly  that  tolerance  is  established.  In  infants,  the 
open  sutures  and  fontanelles  and  the  soft  bones  yield  more  readily 
to  the  expansion  and  produce  less  actual  compression. 

The  uniform  enlargement  of  the  head  and  the  depressed  eyes 
are  characteristic.  The  globular  or  pyriform  shape  of  the  enlarged 
head  should  be  compared  with  the  squared  head  of  the  rachitic 
child.  The  head  should  be  measured  from  time  to  time  and  its 
size .  and  rate  of  growth  compared  with  normal  standards.  Holt 
gives  the  rule  that  if  the  head  grows  more  than  an  inch  in  a  month 
there  can  be  little  doubt  of  hydrocephalus. 

The  disease  may  become  arrested  spontaneously  at  any  stage 
and  remain  in  that  state;  but  in  most  cases  it  is  progressive  with 
greater  or  less  rapidity  and  either  steadily  or  with  exacerbations, 
until,  within  the  first  year  or  the  first  few  years,  death  comes  by  ex- 
haustion through  inanition,  often  with  convulsions  at  the  last;  or 
the  patient  is  carried  off  by  some  intercurrent  disease. 

Treatment. — Mercury  and  potassium  iodide  should  be  tried  in 
in  all  cases.  If  the  disease  is  due  to  syphilis  these  remedies  will 
prove  beneficial ;  and  in  some  cases  in  which  I  could  get  r^o  evi- 
dence whatever  of  syphilis  they  have  stayed  the  progress  of  the 
disease  at  least  for  a  time.  I  know  of  no  other  drugs  that  will  do 
even  that  much,  and  they  will  not  always.  Smearing  the  shaved 
scalp  with  ointment  of  iodoform  and  covering  it  with  bandages  and 
tight  strapping  does  no  good;  nor  do  innumerable  other  drugs  and 
procedures.  The  mercury  may  be  used  by  inunctions  to  the  scalp, 
or  elsewhere,  or  administered  internally. 

Very  numerous  operative  measures  have  been  tried — aspira- 
tions, repeated  aspirations,  injections  of  Morton's  fluid,  and  of  iodine 
solutions.  Since  Quincke's  introduction  of  lumbar  puncture  this 
procedure  has  been  used,  not  only  for  acute  but  for  chronic  hydro- 
cephalus. 

Lumbar  Puncture. — Lumbar  puncture  is  perhaps  not  too 
familiar  to  be  described  here.  An  aspirating  needle  or  the  smallest 
sized  trocar  and  canula  is  the  instrument  selected  and  sterilized  by 
boiling.  Quincke's  especially  devised  fine  trocar  and  canula  is  the 
best.  An  ordinary  hypodermic  needle  will  perhaps  do  if  it  is  long 
enough,  but  a  thin  needle  may  be  broken.  No  syringe  or  suction 
apparatus  is  necessary  or  advisable.  The  skin  over  the  lumbar 
region  is  as  carefully  cleansed  with  antiseptics  as  if  for  a  capital 


THE  HEAD   AND   BRAIN  353 

operation.  The  child's  spine  is  bent  forward  with  thighs  tightly 
flexed  upon  abdomen,  and  firmly  held  in  that  position.  Babies  and 
comatose  patients  need  no  general  anesthetic.  Ethyl  chloride  spray 
may  be  used,  or  a  single  small  drop  of  carbolic  acid  touched  upon 
the  skin.  Quincke  drew  attention  to  the  fact  that  while  in  the  newly 
born  the  spinal  cord  reaches  to  the  third  lumbar  vertebra,  by  .the 
time  the  babe  is  one  year  old  development  has  extended  the  canal  so 
that  the  cord  reaches  only  to  the  second ;  and  that  the  nerves  com- 
posing the  Cauda  equina  are  grouped  into  two  bundles,  one  lying 
upon  each  side  of  the  canal  and  not  likely  to  be  wounded  by  a  cen- 
tral puncture.  The  puncture  is  usually  made  in  the  interval  between 
the  third  and  fourth  lumbar  vertebrae.  This  is  in  very  nearly  a 
straight  line  between  the  iliac  crests,  and  can  usually  be  felt  if  not 
seen.  The  space  between  the  fourth  and  fifth  vertebrae  will  do  as 
well.  The  needle  is  entered  just  at  one  side  of  the  median  line  to 
avoid  the  spinous  process,  and  at  right  angles  to  the  surface,  or 
pointed  a  little  upward.  It  passes  between  the  vertebral  bodies, 
traversing  the  ligamentum  subflavum  and  the  theca,  and  enters  the 
spinal  canal  at  a  depth  of  1.5  to  2.5  centimeters,  equal  to  three-fifths 
to  one  inch.  It  is  not  permissible  to  turn  the  needle  in  this  or  that 
direction  in  search  of  the  canal  after  it  is  deeper  than  the  integu- 
ments ;  but  there  is  usually  not  the  least  difficulty.  The  fluid  gen- 
erally flows  the  instant  the  canal  is  tapped.  It  is  very  seldom  that 
it  is  too  thick  to  flow,  or  contains  flocculi  that  may  plug  the  canula 
and  require  dislodgment  or  a  reintroduction.  It  is  apt  to  spurt  if 
there  is  great  tension,  or  may  only  drip  slowly  and  yet  yield  a 
considerable  quantity.  If  the  head  is  much  retracted,  straightening 
the  neck  may  cause  the  fluid  to  flow ;  as  will  also  raising  the  patient 
to  the  sitting  position.  The  fluid  should  be  caught  in  sterilized  test 
tube  or  flask  for  measurement  and  examination.  From  a  drachm. 
or  two  to  an  ounce  or  sometimes  more  may  be  withdrawn.  When 
the  canula  is  withdrawn  the  puncture  is  sealed  with  collodion. 

The  fluid  from  a  case  of  cerebro-spinal  meningitis  is  slightly 
cloudy.  This  is  better  seen  by  comparing  with  filtered  water.  The 
meningococcus  may  be  found  upon  microscopic  examination. 

In  tubercular  meningitis  the  fluid  is  clear.  On  standing  in  a 
test  tube  several  hours  a  filmy  white  column  may  form  in  its  center. 
Often  no  organisms  whatever  are  found  by  the  microscope. 

In  hydrocephalus  the  fluid  withdrawn  is  clear  and  has  the  com- 
position of  cerebro-spmal  fluid,  sometimes  slightly  more  albuminous, 
or  it  may  contain  sugar. 

Tapping  the  Ventricle  and  Permanent  External  Drain- 
age.— Tapping  of  the  distended  ventricles  through  the  skull  is  a  very 
old  method  of  treating  hydrocephalus,  which  had  long  been  discon- 
tinued on  account  of  its  fatality,  although  quite  a  number  of  cures 


354  SURGICAL   DISEASES    OF    CHILDREN 

were  reported.  After  the  introduction  of  Listerism  it  was  revived 
and  tried  again,  with  many  modifications  of  technique.  The  punc- 
ture can  be  made  either  through  a  fontanelle  in  infants  or  through 
a  cranial  bone,  avoiding  the  situation  of  any  large  vessel,  and 
usually  the  motor  zone  (Keen).  Park  chooses  the  point  3  cm.  be- 
hind the  external  auditory  meatus  and  the  same  distance  above  the 
base  line  of  the  skull  Here,  after  trephining,  the  aspirating  needle 
or  a  permanent  drain  may  be  introduced.  The  puncturing  instru- 
ment or  the  drainage  should  be  introduced  in  a  direction  toward 
a  point  6  cm.  above  the  meatus  of  the  opposite  side.  Although 
drainage  can  be  effected  in  this  manner  and  the  wound  kept  aseptic 
for  a  time,  it  is  practically  impossible  to  maintain  asepsis  indefinite!}- 
with  open  drainage,  and  meningitis  and  death  result. 

Drainage  into  Subcutaneous  Areolar  Tissue. — McArthur 
successfully  drained  the  lateral  ventricles  into  the  cellular  tissues 
beneath  the  scalp.  He  inserted  a  silver  tube  with  a  flange  at  its 
outer  end  through  a  hole  drilled  above  and  behind  the  ear.  A 
similar  plan  with  a  gold  tube  was  used  by  Miculicz.  Troje  used 
glass  wool  as  a  drainage  material  for  the  lateral  ventricle.  I.  S.  Hors- 
ley  attempted  to  drain  from  the  vertex  into  the  subcutaneous  tissues 
of  the  neck  with  catgut  and  with  silk  drains.  (Jour.  A.  j\I.  A., 
July,  1906.)  Kocher  prefers  to  tap  the  lateral  ventricle  through 
the  skull  just  in  front  of  the  bregma,  2  cm.  to  one  side  of  the 
mesial  line,  and  directing  the  needle  downward  and  backward.  His 
reason  for  choosing  this  point  is  that  the  ventricle  is  much  deeper 
than  it  is  wide,  and  there  is  some  danger  in  puncturing  transversely 
or  injuring  the  inner  wall ;  or  that  the  tube  will  impinge  on  the 
inner  wall  as  the  distended  ventricle  collapses.  (25) 

Drainage  into  Pleural  Cavity  or  into  the  Spinal  Canal. 
— Drainage  into  the  pleural  cavity  has  been  attempted  ( Sherman,  So. 
Cal.  Prac,  Dec,  1907),  by  carrying  drainage  subcutaneously  from 
an  opening  through  the  calvarium  and  into  the  lateral  ventricle, 
down  the  neck  and  into  a  pleural  opening  between  the  first  and 
second  ribs ;  and  drainage  into  the  spinal  canal  by  removal  of  one 
lamina  is  suggested  by  the  same  writer. 

Permanent  Drainage  into  the  Subdural  Space. — Dr. 
Leonard  Hill  found  by  a  series  of  experiments  ^  that  "  the  tension  of 
the  cerebro-spinal  fluid  and  the  cerebral  venous  tension  are  normally 
the  same,"  on  account  of  the  fact  that  fluid  escapes  directly  into 
the  veins  from  the  subdural  and  subarachnoid  spaces  at  any  pressure 
above  the  venous  pressure.  He  also  proved  experimentally  that 
"  no  pathological  increase  of  cerebral  tension  can  be  transmitted 
by  the  cerebro-spinal  fluid,  because  this  fluid  can  never  be  retained 

i"The  Physiology  and  Pathology  of  the  Cerebral  Circulation," 
London,  1896. 


THE   HEAD   AND   BRAIN  355 

in  the  meningeal  spaces  at  a  tension  higher  than  that  in  the  cere- 
bral veins."  One  of  the  theories  that  has  been  advanced  to  explain 
the  method  of  the  production  of  chronic  hydrocephalus  is,  that  the 
channel  through  which  the  fluid  secreted  in  the  lateral  ventricles 
should  pass  in  order  to  escape  into  the  arachnoid  space  outside  of 
the  foramen  of  Majendie  has  been  closed  or  partly  closed;  thus  the 
fluid  accumulates  in  the  ventricles  and  distends  them  and  expands  the 
cortex,  compressing  it  against  the  cranium.  Reasoning  from  this  and 
from  Dr.  Hill's  experimental  findings,  Sutherland  and  Cheyne  ^  pro- 
ceeded to  relieve  this  intracerebral  tension.  If  an  outlet  for  the  su- 
perabundant ventricular  fluid  were  provided  so  that  it  might  escape 
into  the  meningeal  spaces,  it  should,  according  to  Dr.  Hill,  be  ab- 
sorbed by  the  veins  until  the  cerebral  venous  pressure  and  the  cere- 
bro-spinal  pressure  were  equalized.  Their  plan  consisted  in  making 
an  opening  through  the  cortex  cerebri  and  introducing  a  drain 
which  would  maintain  a  free  passage  between  the  ventricle  and 
the  subdural  or  subarachnoid  space.  They  describe  the  operation 
as  follows :  "  A  curved  incision  about  an  inch  and  a  half  long 
v/as  made  over  the  left  lower  angle  of  the  anterior  fontanelle,  and 
the  skin  and  deeper  tissues  were  turned  down  from  off  the  dura 
mater.  A  small  incision  about  a  quarter  of  an  inch  in  length  was 
then  made.  There  was  no  fluid  in  the  subdural  space.  Before  the 
operation  a  catgut  drain  was  made  as  follows:  A  bundle  of  finest 
catgut,  containing  16  strands  and  about  two  inches  long,  was  pre- 
pared, one  end  of  the  bundle  being  tied  together  and  the  other  being 
free.  As  soon  as  the  dura  mater  was  incised,  the  tied  end  of  this 
bundle  was  seized  with  a  pair  of  sinus  forceps  and  pushed  down- 
wards and  slightly  backwards  between  the  brain  and  the  dura  mater 
for  about  an  inch.  The  other  end  of  the  drain,  which  projected 
through  the  slit  in  the  dura  mater,  was  then  grasped  with  the  sinus 
forceps  and  pushed  through  the  substance  of  the  brain  into  the 
expanded  lateral  ventricle.  The  brain  v/as  very  thin  at  this  point 
and  clear  fluid  escaped  immediately.  Having  thus  arranged  one 
end  of  the  drain  in  the  subdural  space  and  the  other  in  the  ventricle, 
three  fine  catgut  stitches  were  employed,  in  completely  closing  the 
opening  in  the  dura  mater,  and  the  skin  was  stitched  up  with  a 
continuous  silk  suture."  They  reported  three  cases  operated  upon 
by  this  method,  the  first  of  which  died  three  months  after  operation 
with  symptoms  of  basilar  meningitis.  The  third  case  died  of  measles 
complicated  with  broncho-pneumonia  a  fortnight  after  the  operation. 
The  second  case  presented  results  which  may  be  hoped  for  in  such 
cases.  It  was  "  a  case  of  advanced  hydrocephalus  in  an  infant 
three  months  old.     All  the  bones  of  the  skull,  vertical  and  basal, 

1 "  The     Treatment     of     Hydrocephalus     by     Intracranial      Drainage," 
Brit.  Med.  Jour.,  Oct.  15,  1898. 


356  SURGICAL   DISEASES    OF   CHILDREN 

were  widely  separated,  and  mental  and  physical  development  had 
been  stationary  since  birth.  .  .  .  The  disturbance  caused  by 
the  operation  was  trifling  and  transient,  there  being-  a  rise  in  tem- 
perature for  a  few  days,  some  restlessness  at  night,  and  vomiting. 
The  dressings  were  removed  on  the  sixth  day  and  the  wound  was 
found  to  be  healed.  The  head  was  smaller  in  all  its  dimensions, 
the  tension  of  the  fontanelle  was  absent,  the  spaces  between  the 
individual  bones  were  less  and  the  proptosis  of  the  eyes  was  not  so 
marked.  The  skull  appeared  to  be  asymmetrical,  as  if  the  left  side 
had  moved  backward  on  the  right.  A  fortnight  after  the  opera- 
tion it  was  noted  that  the  bones  at  the  base  of  the  skull  and  the  parie- 
tal were  overriding,  while  there  was  still  a  slight  interval  between 
the  two  parietal  bones.  A  flannel  bandage  was  applied  to  the  head 
to  keep  up  the  external  pressure  and  aid  absorption.  A  few  days 
later  a  slight  increase  of  tension  was  noted  in  the  fontanelle,  but 
this  soon  passed  off.  A  month  after  the  operation  the  child  was 
taking  nourishment  well,  the  cry  was  stronger  and  the  head  was 
moved  freely.  The  bones  of  the  cranium  were  all  overriding,  and 
the  only  unclosed  space  was  the  anterior  fontanelle,  which  measured 
3^  inches  in  the  transverse  diameter.  .  .  .  For  the  next  two 
and  a  half  months  the  condition  remained  practically  stationary, 
and  during  this  period  the  patient  passed  successfully  through  an 
attack  of  measles.  .  .  .  The  head  having  been  shaved,  the 
following  curious  state  of  affairs  was  manifested:  The  asymmetry 
of  the  skull,  which  had  been  previously  noted,  was  much  more 
marked,  the  right  side  being  evidently  larger  than  the  left.  The 
right  side  of  the  fontanelle  was  prominent,  tense  and  fluctuating, 
and  on  a  tracing  being  taken  was  seen  to  cover  a  much  larger  area 
than  the  left  half,  which  was  not  elevated.  The  left  parietal  was 
overriding  the  left  frontal  bone,  while  on  the  right  side  the  corre- 
sponding bones  were  merely  in  contact.  It  was  apparent  that  while 
the  drainage  of  the  left  ventricle  had  been  as  complete  as  possible, 
that  of  the  right  had  come  to  a  standstill,  and  the  fluid  was  again 
increasing.  Accordingly  an  operation  was  performed  on  the  right 
side  of  the  head  similar  to  that  performed  on  the  left  four  months 
previously.  On  opening  the  dura  mater  the  brain  bulged  at  once, 
there  being  no  adhesions  and  no  extra-cerebral  fluid.  On  punctur- 
ing the  brain,  fluid  was  reached  at  a  very  short  distance  from  the 
surface,  and  flowed  at  first  with  some  force.  A  catgut  drain  was 
introduced  in  the  usual  manner.  This  operation  was  followed  by 
complete  disappearance  of  intra-cranial  tension  and  gradual  dim- 
inution in  size  of  the  right  side  of  the  head.  At  the  present  time, 
six  months  after  the  first  operation  and  a  month  after  the  second, 
the  fontanelle  measures  two  inches  transversely,  and  all  the  bones 
of  the  cranium  are  overriding   in  an   extreme  degree.     There   is 


THE   HEAD   AND   BRAIN  357 

now  a  conjunctival  reflex  and  the  child  can  see.  She  is  gaining 
weight,  and  moves  the  head  and  hmbs  much  more  freely.  There 
are  no  evidences  of  mental  development."  The  authors  conclude 
that  Dr.  Hill's  observations  on  the  absorption  of  cerebro-spinal  fluid 
by  the  meninges  also  hold  good  in  the  pathological  condition  of 
hydrocephalus.  But  the  establishment  of  the  drainage  by  a  per- 
manent opening  is  a  matter  of  difficulty  in  some  cases.  "  First, 
the  brain  tissue  may  be  so  thick  as  to  close  in  around  the  catgut 
drain  and  to  prevent  the  passage  of  the  fluid;  secondly,  the  inflam- 
mation set  up  by  the  wounds  in  the  dura  mater  and  the  cerebral 
cortex  may  lead  to  the  formation  of  adhesions  around  the  artificial 
outlet  which  seal  it  up.  This  difficulty  may  be  met  by  making  the 
opening  in  the  cortex  as  far  as  possible  from  that  in  the  dura  mater 
and  allowing  so  much  fluid  to  escape  as  will  prevent  the  opposed 
surfaces  from  coming  immediately  in  contact.  Further  experience 
is  required  both  as  to  the  best  kind  of  drain  for  the  purpose  and 
the  manner  in  which  it  is  to  be  employed."  Sutherland  and  Cheyne 
also  note  that  drainage  of  both  lateral  ventricles  by  operation  upon 
one  side  cannot  in  all  cases  be  depended  upon,  as  the  usually  free 
communication  between  the  ventricles  through  the  foramen  of 
ISIonroe  may  be  closed  by  descent  of  the  falx  cerebri  as  the  en- 
largement of  the  head  decreases.  They  also  suggest  hope  of  relief 
by  intracranial  drainage  in  other  diseases  than  chronic  hydro- 
cephalus, in  which  ventricular  pressure  becomes  a  dangerous  com- 
plication— such  as  tubercular  meningitis,  simple  basilar  meningitis, 
and  tumor  cerebri. 

In  hydrocephalus  relief  of  tension  may  not  restore  cerebral 
function.  Obviously  cerebral  function  which  never  existed  cannot 
be  restored.  The  amount  of  improvement  in  cerebration  which  can 
be  expected  must  depend  upon  development  of  the  brain.  If  the 
brain  had  been  considerably  developed  before  the  fluid  pressure 
put  a  stop  to  its  development,  relief  of  that  pressure  may  restore 
function.  The  longer  the  tim.e  that  passes  without  mental  develop- 
ment or  relief  of  the  retarding  pressure  the  less  the  hope  of  subse- 
quent mental  improvement.  This  emphasizes  the  importance  of 
early  diagnosis  and  early  operation  in  chronic  progressive  hydro- 
cephalus. In  discussing  the  work  of  Sutherland  and  Cheyne,  Dr. 
Still  presented  the  importance  of  distinguishing  between  cases  of 
congenital  hydrocephalus  from  those  of  simple  posterior  basic  menin- 
gitis for  the  reason  that  the  diplococcus  of  posterior  basic  menin- 
gitis might  exist  in  the  fluid  in  the  lateral  ventricles  as  late  as  the 
one  hundred  and  third  day  Tand  perhaps  longer,  the  proper  date 
being  yet  undetermined)  after  the  acute  stage  of  the  disease  was 
over.  In  operation  in  such  cases  there  might  be  risk  of  further 
infection  by  draining  the  fluid  into  the  subdural  space. 


358 


SURGICAL   DISEASES    OF   CHILDREN 


Figs.  125  and  128  are  from  original  photographs  of  G,  G., 
aged  18  months.  Parents  both  healthy  and  this  their  first  baby. 
No  miscarriages  preceded  it.  Normal  pregnancy  and  delivery. 
When  three  months  old  parents  noticed  baby's  eyes  depressed  in 
their  sockets,  and  considered  him  a  very  cross-tempered  baby. 
His   head   then   measured    18   inches.     Baby   had  no   disease  but 


Fig.  128.  Autopsy  on  case  of  chronic  internal  hydrocephalus  shown  in 
Fig.  125  three  weeks  after  operation.  The  thin  and  fragile  cortex  which 
collapsed  as  soon  as  emptied,  and  the  distended  vessels  are  well  shown. 
The  bundle  of  silkworm  gut  used  for  subdural  drainage  may  be  seen 
projecting  into  the  distended  left   lateral   ventricle. 

chicken  pox  at  twelve  months,  but  his  head  gradually  expanded  until 
at  eighteen  months  it  measured  24^  inches  in  circumference  and 
19I  inches  over  the  vertex  from  ear  canal  to  ear  canal,  and  18 
inches  from  occiput  to  glabella.  Total  length  of  the  infant  was 
32f  inches,  of  which  9  inches  represented  the  head  from  chin  to 
vertex.  The  anterior  fontanelle  measured  8  inches  each  way,  an- 
tero-posteriorly  and  laterally.  The  cranial  bones  were  separated 
and  the  left  parietal  near  the  fontanelle  was  more  lacking  in  ossi- 
fication than  the  right.  The  scalp  was  traced  by  large  prominent 
veins  and  bore  scanty  hair.     The  mental  development  was  very 


THE   HEAD    AND    BRAIN 


359 


low.  He  would  cry  when  hungry  or  thirsty.  If  there  was  any 
vision  it  was  slight.  Hearing-  was  present.  He  made  no  articulate 
sound,  but  when  in  a  good  humor,  if  spoken  to  would  "  gabble," 
giving  several  inflections  and  variations  of  tone,  but  no  meaning. 
He  would  sometimes  laugh.  He  could  not  sit  up  nor  support  the 
head,  and  was  entirely  helpless.  Operated  by  the  writer  at  St. 
Clair  Hospital,  August,  1904,  by  the  method  described  by  Suther- 
land and  Cheyne,  excepting  that  a  half  dozen  strands  of  finest  silk- 
worm gut  instead  of  catgut  was  used  for  the  drain.  The  cerebral 
cortex  was  as  thin  as  chamois  skin.  The  tension  in  the  ventricle 
was   so  great  that   considerable  fluid   escaped   through   the   small 


Fig.    129.     Ballance's   operation   for    hydrocephalus   internus.     Binnie's 

Operative  Surgery. 

incision  in  the  dura  before  it  could  be  closed.  The  temperature  went 
up  for  a  few  days  but  subsided;  the  wound  healed  promptly,  and 
the  babe  did  well  for  10  or  12  days,  when  it  gradually  sank  and 
died  in  3  weeks,  apparently  of  exhaustion,  the  end  coming  with 
convulsions.  Autopsy  showed  the  operation  wound  healed  with 
the  membranes  adherent  at  this  point.  At  the  site  of  the  opening 
into  the  left  ventricle  the  drain  was  still  adhering  to  the  cortex,  sur- 
rounded by  plastic  lymph  which  peeled  off.  The  ventricles  were 
filled  with  watery,  pale  yellow-tinged  fluid,  on  evacuating  which 
the  brain,  being  thin  and  soft,  collapsed.  The  membranes  Vk'ere 
somewhat  thickened  and  their  vessels  exaggerated  in  promi- 
nence. 

On  account  of  the  difficulty  of  maintaining  the  opening  free 
with  the  catgut  drain,  Ballance  uses  a  very  fine  L-shaped  tube  of 
pure  platinum  or  of  gold  and  iridium  (pure  gold  is  too  soft).  One 
arm  of  the  tube  near  the  angle  is  provided  with  a  small  ring 
through  which  a  suture  may  be  passed  to  attach  it  to  the  dura.  The 
other  arm  of  the  tube  is  made  to  penetrate  the  cortex  into  the 
ventricle,  while  the  one  with  the  ring  lies  immediately  beneath  the 


36o 


SURGICAL   DISEASES    OF   CHILDREN 


dura,  being  sutured  in  position.^  (See  Fig.  129.)  He  finds  that 
after  subdural  drainage  it  may  be  that  the  fluid  continues  to  form 
and  one  may  think  his  tube  is  blocked,  when  on  opening  the  skull 
he  finds  that  an  internal  has  been  converted  into  an  external  hydro- 
cephalus, because  the  Pacchionian  bodies  have  failed  to  absorb  the 
fluid.  Ballance  has  treated  a  number  of  cases  of  chronic  hydro- 
cephalus by  ligation  of  both  common  carotids  at  an  interval  of 
about  ten  days,  with  recoveries  in  several  cases.  If  this  fails  to 
stop  the  secretion  of  an  abnormal  amount  of  fluid,  then  he  advises 
a  trial  of  subdural  drainage. 

INTRACRANIAL  TUMORS 

Children  are  neither  more  nor  less  liable  than  adults  to  tumors 

within  the  cranium,  but 
the  relative  frequency 
with  which  the  varieties 
are  found  differs,  and 
the  location  differs  ac- 
cording to  the  variety. 
Boys  are  twice  as  liable 
as  girls ;  and  no  age  is 
exempt.  Children  under 
eight  years  are  some- 
more  liable  than 
above  that  age. 
has  been  added 
of  late  years  to  the  es- 
sential facts  of  the  nat- 
ural history  of  intracra- 
nial growths.  Advance- 
ment has  been  made  in 
the  surgical  treatment  of 
these  conditions. 
Operative  Treatment  of  Brain  Tumor. — All  cases  of  intra- 
cranial tumor  as  well  as  of  abscess  and  chronic  hydrocephalus  which 
do  not  yield  to  medical  treatment  within  a  reasonable  time  should 
be  subjected  to  operation  if  the  symptoms  point  to  disease  that  is 
accessible.  Tumors  upon  the  convexity  or  in  the  great  longitudinal 
fissure  can  generally  be  reached.  But  the  tumor  being  accessible, 
it  does  not  follow  that  it  is  removable.  A  large  infiltrated  sarcoma 
or  glioma  might  be  reached  and  yet  on  account  of  its  indeterminate 
limits  and  extensive  implication  of  brain  structure  be  impossible  of 
removal.  An  encapsulated  tumor  or  a  hard,  non-vascular  tumor 
can  generally  be  removed  if  it  can  be  reached.  Tumors  of  the  cere- 
1  American  Surg.  Assn.,   Alay  31,   1906. 


Fig.  130.  Chiene's  lines  marked  upon 
the  scalp  of  a  child  5  years  of  age. — 
Edinburgh  Stereoscopic  Atlas  of  Anat- 
omy. 


what 
those 
Litde 


THE   HEAD   AND   BRAIN 


361 


bral  axis  are  practically  out  of  reach ;  and  with  tumors  of  the  cere- 
bellum, on  account  of  the  uncertainties  of  diagnosis  and  the  dangers 
of  interference  with  that  portion  of  the  brain,  it  is  only  the  very  ex- 
ceptional case  that  justifies  an  attempt. 

Brain  tumor  may  require  operation  not  only  for  removal,  but 
for  the  relief  of  pressure.  Operation  is  justifiable  if  pressure 
symptoms,  such  as  convulsions,  coma,  paralysis,  choked  discs,  pain 
or  other  distressing  symptoms,  become  severe. 

CRANIO-CEREBRAL  TOPOGRAPHY 

In  cases  requiring  operation  for  intracranial  abscess,  brain 
tumor,  drainage  of 
ventricles,  and  many 
other  intracranial  con- 
ditions, it  becomes  nec- 
essary to  localize  the 
different  parts  of  the 
brain  and  its  mem- 
branes and  of  the  skull 
with  reference  to  the 
surface  of  the  head. 
In  order  to  do  this  we 
must  not  only  avail 
ourselves  of  the  prom- 
inent landmarks  of  the 
cranium  but  must  sup- 
plement them  with 
certain  arbitrary  lines, 
just  as  lines  of  latitude 
and  longitude  measure 
the  terrestrial  globe. 
From  the  many  ingen- 
ious systems  for  this  purpose,  such  as  those  of  Broca,  Championiere, 
Horsley,  Chipault,  and  numerous  modifications  and  combinations,  I 
have  chosen  to  present  the  system  introduced  by  Chiene,  as  illus- 
trated in  the  Edinburgh  Stereoscopic  Atlas  of  Anatomy.  The  points 
used  are  the  following : 

G,  the  glabella,  a  point  midway  between  the  superciliary  ridges. 
O,  the  inion  or  external  occipital  protruberance.  E,  the  external 
angular  process  of  the  frontal  bone,  which  projects  at  the  outer 
angle  of  the' orbit.  P,  the  root  of  the  zygoma,  a  point  immediately 
above  and  in  front  of  the  external  auditory  meatus.  S,  seven- 
eighths  point  between  glabella  and  inion.  T,  three-quarter  point  be- 
tween glabella  and  inion  (the  lambda).  AI,  midpoint  between  gla- 
bella and  inion.     B,  parietal  eminence,  intersection  of  AIR  and  TE. 


Fig.  131.  The  scalp  has  been  removed 
from  the  surface  of  the  cranium  over 
the  area  marked  out  in  Fig.  130,  and 
the  sutures  are  show^n. — Edinburgh 
Stereoscopic   Atlas   of   Anatomy. 


362 


SURGICAL   DISEASES    OF   CHILDREN 


N,  midpoint  of  EP.  C,  midpoint  of  AB.  R,  midpoint  of  PS.  CD 
parallels  MN.  A,  intersection  of  MN  and  TE,  pterion  or  in  the 
child  rather  above  it.  Anterior  division  middle  meningeal  artery. 
These  points  and  the  accessory  lines  are  seen  in  Fig.  130, 
marked  upon  the  head  of  a  child  five  years  old,  for  the  reason 
that  the  anatomy  of  the  child  differs  somewhat  from  that  of  the 
adult.  In  Fig.  131  the  scalp  has  been  removed  from  the  cranium 
over  the  area  marked  out  on  Fig.  130,  and  the  sutures  are  shown. 
The  sutures  are  of  limited  value  as  landmarks  for  the  brain,  but 
their  position  must  be  borne  in  mind  lest  the  line  of  suture  be  mis- 
taken for  fracture  in  injuries  of  the  head. 

The  coronal   suture  passes  transversely  across  the  head  but 
-  is  in   front  of  the  mid- 

point M. 

The  lambdoidal  suture 
is  between  the  occipital 
and  parietal  bones. 

The  spheno  -  parietal 
suture  is  between  the 
anterior  inferior  angle 
of  the  parietal  and 
the  great  wing  of  the 
sphenoid.  It  is  known 
as  the  pterion,  and  it 
overlies  fhe  point  of 
division  of  the  Sylvian 
fissure  into  its  three 
limbs,  and  the  bifurca- 
tion of  the  middle  men- 
ingeal artery,  or  its 
anterior  division. 

The  squamous  suture, 
between  the  parietal 
bone  and  the  squamous  part  of  the  temporal,  beginning  at  the 
pterion  and  arching  back  to  the  asterion  or  junction  of  the  parietal, 
temporal,  and  occipital  bones.  The  highest  part  of  this  suture 
reaches  up  to  the  lower  end  of  the  fissure  of  Rolando. 

In  Fig.  132  the  skullcap  has  been  removed  and  the  outer  sur- 
face of  the  dura  mater  is  exposed.  The  outer  surface  of  the  dura 
mater  is  strongly  adherent  to  the  skull,  especially  along  the  lines 
of  the  cranial  sutures.  The  meningeal  arteries  ramify  between 
the  membrane  and  the  bone  and  supply  both  of  them  with  blood. 
The  largest  of  the  meningeal  arteries  is  the  middle  meningeal.  A 
branch  of  the  internal  maxillary,  which  enters  the  skull  through 
the   foramen   spinosum   in   the  great  wing   of  the   sphenoid,  and 


Fig.  132.  The  skull  cap  has  been  removed, 
exposing  the  dura  mater.  The  meningeal 
arteries  and  a  portion  of  the  lateral  sinus 
are  well  shown. — Edinburgh  Stereo- 
scopic Atlas   of  Anatomy. 


THE   HEAD   AND   BRAIN 


363 


extends  outward  and  slightly  forward  on  the  great  wing  of  the 
sphenoid.  Its  course  and  main  branches  are  shown  in  Fig.  132. 
The  lateral  sinus  may  be  divided  into  two  parts,  of  which  the 
first  is  seen  here,  passing  from  the  region  of  the  external  occipital 
protuberance,  to  a  point  about  three-quarters  of  an  inch  below  and 
behind  the  center  of  the  external  auditory  meatus,  describing  a  curve 
with  the  convexity  directed  upward.  The  second  part  of  the  vessel 
occupies  a  deep  groove 
on  the  mastoid  portion  of 
the  temporal  bone  and  on 
the  jugular  process  of 
the  occipital  bone. 

In  Fig.  133  the  dura 
mater  has  been  removed, 
the  fine  membranes 
stripped  from  the  sur- 
face of  the  brain,  expos- 
ing the  outer  aspect  of 
the  hemisphere ;  and  the 
position  of  some  of  the 
principal  motor  and  sen- 
sory centers  has  been 
marked  upon  it.  The 
fissures  and  convolutions 
at  this  age — five  years — 
are  fully  developed.  But 
it  should  be  borne  in 
mind  that  the  fissures  of 
the  brain  of  the  child  do 
not  in  all  cases  bear  the 
same  relationship  to  the 
cranial  sutures  as  do  those  of  the  adult.  Important  differences  exist, 
associated  mainly  with  the  differences  in  the  proportioned  sizes  of 
different  lobes  of  the  brain.  At  birth  the  Sylvian  fissure  lies  above 
the  squamo-parietal  suture,  but  the  fissure  and  the  suture  approach 
one  another  rapidly  up  to  the  fifth  year,  at  which  age  the  fissure 
lies  about  14  mm.  above  the  suture.  In  the  adult  the  fissure  may  lie 
above,  below  or  subjacent  to  the  suture.  Chiene's  surface  lines 
drawn  upon  the  head  of  the  child  also  place  the  Sylvian  point  above 
the  suture,  but  the  fissure  lies  at  a  slightly  higher  level  even  than 
this  point.  The  fissure  of  Rolando  maintains,  after  birth,  a  very 
constant  position  in  relation  to  the  surface,  at  both  its  upper  and  its 
lower  ends.  By  comparing  Fig.  133  with  Fig.  130  it  will  be  seen 
that  the  Rolandic  area  lies  within  the  quadrangular  figure  A.  C,  D, 
M,  but  it  must  be  noted  that  the  true  motor  area  is  confined  to  the 


Fig.  133.  Cranio-cereeral  topography. 
The  dura-  and  pia-mater  have  been 
removed,  exposing  the  surface  of  the 
hemisphere.  Some  of  the  principal 
motor  and  sensory  centers  have  been 
marked  upon  the  brain  as  explained  in 
the  text,  and  Chiene's  lines  have  been 
marked  in  the  same  position  as  they  are 
upon  the  scalp  in  Fig.  130. — Modified 
from  the  Edinburgh  Stereoscopic  Atlas 
of  Anatomy. 


364  SURGICAL   DISEASES    OF   CHILDREN 

pre-central  area  and  does  not  extend  behind  the  fissure  of  Rolando. 
It  occupied  mainly  the  ascending  frontal  convolution,  extending 
into  the  depth  of  the  fissure  and  occupying  the  anterior  wall  and  in 
some  places  the  floor.  It  also  extends  into  the  adjacent  portions 
of  the  frontal  convolutions.  The  upper  part  (at  L  in  Fig.  133)  forms 
the  area  for  the  lower  limb  and  below  it  is  the  area  for  the  body. 
Near  the  center  of  the  fissure  of  Rolando,  the  pre-central  convo- 
lution grows  backwards,  deflecting  the  course  of  the  fissure,  and  the 
area  of  the  cortex  which  occupies  the  indentation  so  formed  repre- 
sents the  center  for  the  upper  limb  of  the  opposite  side.  (See  A, 
Fig.  133.)  The  center  for  the  shoulder  lies  highest,  and  lower 
down  are  the  centers  for  the  elbow,  wrist,  fingers,  index  and  thumb. 
The  area  for  the  face  is  continuous  with  the  above  (see  F,  Fig.  133), 
and  the  area  for  the  tongue  occupies  the  lowest  part  of  the  pre- 
central  convolution.  The  centers  for  the  head  and  eyes  occupy  por- 
tions of  the  middle  and  inferior  frontal  convolutions  in  front  of  the 
center  for  the  limbs.  The  figure  2  is  placed  on  the  division  of  the 
Sylvian  fissure,  and  as  has  been  pointed  out,  lies  at  a  slightly 
higher  level  than  the  surface  mark  which  would  indicate  its  position 
in  the  head  of  the  adult.  The  line  A,  C.  Fig.  130,  however,  overHes 
the  posterior  horizontal  limb  of  the  Sylvian  fissure,  and  a  finger's 
breadth  below  that  line  lies  the  parallel  fissure  (3,  Fig.  133),  the 
hinder  end  of  which  is  continued  upwards  into  the  parietal  lobe  to 
the  region  marked  S,  Fig.  133,  where  Hes  the  angular  gyrus  or  cen- 
ter for  word-seeing.  The  center  for  vision  is  situated  at  the  tip 
of  the  occipital  lobe.  (See  V,  Fig.  133.)  The  area  for  hearing  is 
found  in  the  superior  temporal  convolution.  The  letter  B,  Fig.  133, 
overlies  the  area  which  in  the  left  hemisphere  is  the  motor  speech 
center  or  Broca's  convolution.  The  coronal  suture  can  be  seen  to 
lie  in  front  of  the  line  AM  and  therefore  is  well  in  front  of  the 
fissure  of  Rolando. 

OPERATIONS  UPON  THE  CRANIUM 

The  most  thorough  sterilization  of  instruments,  hands,  the  field  of 
operation,  and  everything  that  comes  near  it,  is  an  absolute  necessity. 
Intracranial  wound  infection  is  an  almost  hopeless  condition  (26). 
The  scalp  should  be  shaved,  and  scrubbed  with  soap  and  water ;  then 
with  alcohol  to  remove  sebaceous  or  oily  matters ;  then  with  bi- 
chloride or  carbolic  or  lysol  solution,  and  finally  with  sterile  water. 
If  the  topography  is  to  be  mapped  out,  the  lines  may  be  drawn  upon 
the  shaven  scalp  with  nitrate  of  silver.  In  all  cases  admitting  de- 
lay for  preparation  this  should  be  done  on  the  day  preceding  the 
operation,  and  the  head  afterward  enveloped  in  a  gauze  compress 
wet  with  bichloride  one  to  three  or  four  thousand,  covered  with  oil 
silk  and  cotton  over  night,  and  cleansed  again  by  the  same  steps 


THE   HEAD   AND    BRAIN  365 

before  the  operation.  Care  should  be  exercised  in  the  shaving  and 
in  every  step  of  the  preparation,  that  it  be  done  thoroughly  and  yet 
without  abrasion  which  may  later  become  a  path  for  infection;  and 
without  irritation  of  the  skin  which  may  be  rendered  extremely 
uncomfortable  or  inflamed  by  injudicious  preparation,  A  laxative 
should  be  administered  on  the  evening  before  and  an  enema  on 
tire  morning  of  the  operation.  (See  Section  on  Preparation  for 
Operation.)  Chloroform  is  usually  the  anesthetic  of  choice  in 
operations  upon  head  or  brain.  An  hour  previous  to  the  operation 
a  dose  of  morphine  suited  to  the  age  of  the  child  should  be  ad- 
ministered, remembering  the  extreme  susceptibility  of  the  young 
to  this  drug.  The  morphine  aids  by  making  less  chloroform  neces- 
sary, and,  as  Schaeffer  and  Horsley  have  shown,  it  lessens  hemor- 
rhage by  contracting  the  arterioles  of  the  nervous  system.  The 
careful  administration  of  the  anesthetic  is  a  very  important  matter 
in  brain  surgery,  as  Horsley  has  emphasized ;  but  inasmuch  as  the 
susceptibility  to  morphine  differs  greatly  in  different  children  it 
seems  advisable  in  suitable  cases  to  ascertain  the  appropriate  dose 
by  experiment  a  day  or  two  previous  to  the  operation.  If  the 
raising  of  the  flap  will  obliterate  the  guiding  lines,  certain  points 
must  be  marked  upon  the  skull  itself  by  the  use  of  a  couple  of 
disinfected  tacks  driven  into  it,  or  by  nicking  with  a  drill  or  chisel. 
The  head  may  be  kept  in  convenient  position  by  sandbags. 

Hemorrhage  during  cranio-cerebral  operations  may  be  to  a 
great  extent  prevented  by  the  use  of  a  rubber  band  or  tubing  drawn 
tightly  round  the  head.  Yet  the  oozing  that  follows  its  removal  leads 
some  surgeons  to  omit  the  Esmarch,  Often  it  slips  out  of  place, 
and  after  all  our  main  reliance  is  in  the  pressure  forceps,  ligatures 
and  serrefines.  If  there  is  no  wound  the  scalp  must  be  divided  by 
an  incision.  In  the  mastoid  operation  a  straight  or  slightly  curved 
incision,  followed  by  the  use  of  retractors,  gives  access  to  the  skull. 
If  more  room  is  needed  a  second  incision  at  right  angles  to  the 
first  may  be  extended  backward  from  it.  For  trephining  or  the 
raising  of  a  bone  flap,  usually  a  horseshoe-shaped  incision  is  made 
with  its  convexity  toward  the  occiput  or  its  hinge  toward  the  blood 
supply.  In  infants  and  children  the  scalp  is  more  movable  upon 
and  more  easily  detached  from  the  skull  than  in  the  adult.  The 
periosteum  also  peels  easily,  excepting  at  the  sutures,  where  it  is 
strongly  attached. 

If  it  is  intended  to  make  a  small  opening,  for  instance  with  a 
trephine,  the  scalp  and  periosteum  constitute  the  flap.  If  the  open- 
ing is  to  be  larger  for  removal  of  a  tumor,  some  operators  prefer 
an  osteoplastic  flap  composed  of  skull  and  scalp.  The  "  trap-door  " 
is  cut  through  scalp  and  skull  to  the  membrane  on  three  sides,  but 
the  skull   merely  grooved   externally  on   the   fourth   side,   when   it 


Z<^  SURGICAL   DISEASES    OF  CHILDREN 

hinges  as  the  flap  is  raised  outward.  The  skull  of  the  child  is  better 
suited  than  that  of  the  adult  for  making  the  osteoplastic  "  trap-door." 
In  cutting  through  the  skull  one  can  choose  between  trephine, 
chisel  and  mallet,  various  saws,  for  instance.  Hey's  saw,  saws  or 
drills  worked  by  a  surgical  engine,  and  the  rongeur  or  biting  forceps. 
The  surgical  engines  and  their  attachments  sometimes  work  beauti- 
fully; but  frequently  they  are  abandoned  and  the  operation  corfl- 
pleted  by  hand.  The  chisel  and  mallet  are  preferred  by  some  opera- 
tors for  opening  the  skull,  but  the  jarring  of  the  blows  is  an  objec- 
tion, and  certainly  may  do  local  damage  in  some  cases,  besides 
adding  to  shock.  To  make  a  small  opening,  for  instance  to  gain 
access  to  the  mastoid  cells,  a  chisel  and  mallet  or  the  Russian  per- 
forator work  well.  In  softened  bone  often  a  drill  or  gouge  held  in 
the  hand  are  sufficient.  For  removing  a  portion  of  the  cranium  a 
good  conical  trephine  and  rongeur  will  be  found  the  most  satisfac- 
tory instruments.  A  saw  works  well  to  remove  a  large  flap  or  a 
bridge  between  trephined  openings ;  or  such  a  bridge  may  be  re- 
moved by  the  rongeur,  or  by  passing  a  wire  saw  beneath  it  after 
opening  the  way  by  passing  a  grooved  director  between  skull  and 
dura.  The  skull  of  the  child  is  softer  than  that  of  the  adult  unless 
it  is  a  previously  rickety  skull  which  has  become  eburnated.  In 
the  young  the  diploe  are  not  developed,  the  bone  is  more  nearly 
alike  in  structure  through  the  entire  thickness  than  in  the  adult. 
The  inner  table  is  less  vitreous  in  consistency.  One  should  beware 
of  thin  spots  in  a  skull,  lest  the  trephine  enter  unexpectedly.  The 
skull  is  thinner  over  the  sinuses,  the  meningeal  grooves  and  near 
the  fontanelles ;  and  it  may  be  quite  thinned  over  a  tumor.  An 
infant's  skull  may  be  as  thin  as  parchment  in  spots.  The  center-pin 
of  the  trephine  should  be  withdrawn  as  soon  as  a  shallow  groove 
is  cut;  and  great  care  used  as  the  instrument  approaches  the  inner 
surface.  Irrigation  facilitates  the  work  of  the  trephine,  though  it 
may  have  to  be  removed  occasionally  for  clearing  in  carbolized  water 
with  a  sterile  brush.  The  disc  of  bone  should  be  loosened  and  pried 
out  without  injury  to  the  dura.  This  is  quite  closely  adherent  to 
the  skull.  The  edges  of  the  opening  should  be  smoothed  and  all 
bone  dust  and  splinters  removed  before  the  membrane  is  opened. 
Any  blood  clot,  fresh  or  older,  between  skull  and  dura  is  easily 
recognizable  and  should  be  removed.  The  degree  of  intracranial 
tension  can  be  judged  by  the  bulging  of  the  membrane  and  by 
touch.  Deep  discoloration  beneath  the  dura  may  indicate  a  clot  in 
that  situation.  By  making  a  horseshoe  or  triangular  flap  in  the  dura 
the  condition  beneath  may  be  ascertained. 

Park's  suggestion  to  divide  the  operation  into  two  procedures, 
in  some  cases,  is  particularly  applicable  in  children,  for  the  avoid- 
ance of  the  shock  of  a  prolonged  operation,  and  also  of  any  trouble- 
some oozing  of  blood  from  the  bone  wound,  which  latter,  however. 


THE   HEAD   AND   BRAIN  ^67 

may  give  no  trouble.  By  this  plan  the  removal  of  the  bone  and 
exposure  of  the  dura  is  done  at  the  first  sitting,  and  at  the  second 
a  week  or  two  later  the  membranes  are  opened  and  the  remainder 
of  the  work  completed.  After  the  membranes  are  opened  no  antisep- 
tic solutions  are  used  for  irrigation ;  but  sterile  normal  salt  solution 
may  be  used. 

The  dura  is  opened  one-eighth  or  three-sixteenths  of  an  inch 
from  the  edge  of  the  opening  in  the  bone,  the  cut  being  best  started 
with  a  scalpel  but  completed  with  a  blunt  scissors,  severing  four- 
fifths  of  the  circumference  of  the  flap.  (Nancrede.)  The  mem- 
branous flap  being  lifted  the  condition  of  the  brain  is  noted.  Tumor 
beneath  the  cortex  may  cause  a  yellowish  tinge  or  lividity  upon  the 
surface.  Yellow-white  patches  in  the  perivascular  lymphatics  in- 
dicate "  old  mischief."  The  motor  center  searched  for  may  be  lo- 
cated by  lightly  touching  it  with  an  electrode  from  a  very  weak  in- 
terrupted current.  Any  increase  in  tension  in  the  brain  is  noted 
by  its  bulging  into  the  wound.  If  there  is  tumor  beneath  the  cortex, 
it  may  be  necessary  to  make  an  exploratory  incision  into  the  brain. 
Any  necessary  incision  into  the  cortex  should  be  vertical  to  the 
surface  and  in  the  long  axis  of  the  convolutions,  and  with  due 
regard  to  the  blood  supply.  Incisions  should  be  clean  cut,  with 
Horsley's  flexible  knife.  An  endeavor  should  be  made  to  leave 
some  portion  of  each  motor  center ;  but  if  malignant  growth  is  to 
be  excised  it  must  all  be  removed,  extending  the  incision  beyond 
its  boundaries  in  the  white  fibers,  where  recurrence  is  most  apt  to 
take  place.  A  cyst  should  be  curetted  and  drained  or  preferably 
packed.    An  abscess  must  be  cleared  out. 

The  hemorrhage  is  sometimes  a  troublesome  thing  to  man- 
age. A  diploic  vein  may  be  plugged  with  catgut  or  a  bit  of  bone  or 
decalcified  bone  or  antiseptic  wax,  as  suggested  by  Horsley ;  or 
its  walls  crushed  in  with  a  blunt  instrument  or  by  forceps.  If  dural 
vessels  lie  in  the  way  and  must  be  cut,  they  may  be  ligated  either 
after  or  preferably  before  division  by  passing  beneath  them  a  round 
needle  threaded  with  fine  catgut.  Wounds  of  sinuses  may  be  plugged 
with  catgut  or  compressed  with  gauze  for  a  few  days.  The  pia, 
and  especially  its  vessels,  should  be  wounded  as  little  as  possible. 
Its  vessels  should  be  ligated  before  division  and  the  flaps  carefully 
put  aside,  to  be  replaced  when  closing.  Nancrede  alludes  to  that 
common  difficulty  of  having  the  vessels  of  the  pia  cut  through  in 
the  tying  of  the  ligature,  and  like  many  operators  finds  the  small 
old-fashioned  serrefines  very  handy.  If  bleeding  recurs  on  removal 
of  the  serrefines  and  ligatures  repeatedly  cut  off  the  ends  of  the 
vessels,  he  re-applies  the  serrefines  with  threads  attached  to  them  to 
facditate  removal  after  a  few  days.  This  also  saves  time,  a  very 
desirable  thing  in  operating  upon  children.  The  brain  cortex  itself 
is  not  so  very  vascular,  at  least  few  vessels  are  likely  to  spurt. 


368  SURGICAL   DISEASES    OF   CHILDREN 

Pressure  with  a  gauze  sponge  will  probably  control  the  oozing ;  but 
if  necessary  fine  gut  ligatures  should  be  applied.  Park  favors  the 
use  of  a  5  per  cent,  solution  of  antipyrine  sprayed  upon  the  brain 
to  stop  oozing.  Drainage  is  generally  necessary  after  brain  in- 
juries and  operations.  If  it  is  a  pus  case  nothing  but  a  tube  is 
efficient,  except  possibly  a  cigarette  drain  of  rolled  rubber  tissue. 
If  the  wound  is  clean  and  only  serum  or  oozing  blood  are  to  be 
drained  away  the  cigarette  or  a  bundle  of  catgut  serves  for  a 
drain.  Nancrede  and  many  other  surgeons  insist  on  draining  a  bul- 
let track,  especially  if  it,  has  been  probed.  If  a  tumor  or  a  portion 
of  brain  has  been  removed  so  that  a  cavity  exists,  it  is  usually  well 
to  pack  it  with  gauze.  Drainage  should  also  be  supplied,  for  gauze 
will  not  drain.  But  it  will  stop  oozing  and  may  help  to  prevent 
that  frequent  and  dangerous  condition,  edema  of  the  brain,  by 
keeping  up  the  usual  tension  upon  the  veins. 

If  packing  is  required  flaps  may  be  closed  with  secondary  or 
temporary  sutures  which  can  be  untied  and  the  flaps  partly  re- 
tracted at  subsequent  dressings.  Park  uses  5  per  cent,  ointment  of 
naphthalin  upon  tampons  between  the  wound  edges,  so  that  they 
may  not  adhere  and  then  bleed  at  subsequent  dressings.  The 
nature  of  the  case  may  allow  of  closing  the  wound  at  once,  and 
primary  union  may  be  secured.  The  buttons  of  bone  or  other  pieces 
removed  were  formerly  replaced  in  closing.  But  when  detached 
from  both  scalp  and  membrane  they  are  apt  to  lose  their  vitality. 
It  is  better  (having  kept  such  portions  of  bone  immersed  in  anti- 
septic solution  till  the  end  of  the  operation)  to  break  them  into 
fragments  like  coarse  sawdust  and  fill  the  gap  with  them.  (Mc- 
Ewen.)  If  the  wound  is  perfectly  aseptic,  a  plate  of  celluloid  or 
heavy  gold  foil  having  several  perforations  and  cut  to  proper  size, 
may  be  used  to  span  the  gap,  resting  upon  its  margins,  covered  with 
the  periosteum  and  scalp.  Such  a  plate  serves  to  prevent  protrusion 
of  cranial  contents  and  their  adhesion  in  the  scar.  A  plate  or  an 
osteo-cutaneous  flap  may  have  to  be  notched  to  allow  for  drainage 
or  removal  of  packing.  The  dura  is  closed  with  fine  chromicized  cat- 
gut. If  a  portion  of  the  dura  is  lacking,  the  vent  may  be  partly 
closed  by  passing  catgut  sutures  across.  The  scalp  wound  is  su- 
tured with  silkworm  gut  or  fine  silk.  External  dressings  of  anti- 
septic absorbent  gauze  should  be  ample  and  well  secured  in  place, 
not  only  with  a  roller  bandage  but  with  adhesive  strips  or  basting 
threads.  Or  a  starch  bandage  may  be  employed.  The  head  may  be 
steadied  with  sandbags.  The  child  should  be  carefully  watched  and 
kept  in  perfect  physiological  rest,  in  a  quiet,  darkened  room.  The 
excretions  should  he  kept  active.  Low  diet  only  is  allowed  for  the 
first  few  days.  While  adult  patients  who  do  well  may  be  allowed  up 
in  perhaps  ten  days,  a  child  should  be  kept  quiet  for  three  weeks. 


CHAPTER  XIV 

DEFORMITIES    AND    DISEASES    OF    THE    EAR    AND 
INTRACRANIAL    EXTENSION    OF   EAR   DISEASE 

Absence  or  Malformation  of  the  Auricle — Over-Develop- 
ment AND  Prominence  of  the  Auricle  (Macrotia) — Fis- 
tula IN  AuRis  Congenita — The  Meatus  Auditorius  Ex- 
ternus — Anatomy — Congenital  Occlusion  of  the  Meatus 
— Foreign  Bodies  in  the  Ear  Canal — Diffused  Inflamma- 
tion OF  THE  External  Meatus — Diphtheritic  Inflamma- 
tion OF  THE  Ear — Injuries  of  the  Tympanic  Membrane — 
Myringitis  (Inflammation  of  the  Tympanic  Membrane) 
— Inflammation  of  the  Middle  Ear  (Otitis  Media; 
Tympanitis) — Incision  of  the  Membrana  Tympani 
(Myringotomy) — Mastoiditis: — Infective  Thrombosis  of 
THE  Lateral  Sinus — Intracranial  Extension  of  Ear  Dis- 
ease TO  THE  Meninges  or  the  Brain.  (27) 

ABSENCE  OR  MALFORMATION  OF  THE  AURICLE 

The  auricle  may  be  congenitally  absent  or  rudimentary  or 
misshapen.  The  result  of  arrested  development  of  the  auricle  is 
called  microtia.  This  may  be  the  only  malformation  present  in  the 
hearing  apparatus,  but  there  are  usually  others,  to  be  mentioned 
shortly,  associated  with  it ;  and  not  infrequently  the  ramus  of  the 
jaw  also  is  stunted,  as  seen  in  Figs.  134  and  135.  Malformation  of 
the  ear  has  been  considered  as  a  stigma  of  degeneration,  yet  ears 
far  from  the  normal  in  shape  or  position  are  found  upon  normal 
individuals. 

Treatment. — If  the  external  ear  is  entirely  absent  or  is  microtia, 
an  artificial  pinna  may  be  attached.  The  crumpled  or  distorted  auri- 
cle may  sometimes,  but  very  seldom,  be  improved  by  plastic  operative 
work  planned  to  suit  the  special  case. 

OVER-DEVELOPMENT  AND  PROMINENCE  OF  THE  AURICLE 

(MACROTIA) 

The  ears  may  be  unduly  large ;  and  in  addition  they  may  stand 
out  prominently  from  the  head.  This  is  sometimes  called  lop-ear. 
It  causes  conspicuous  deformity  and  great  annoyance  to  the  patient. 

Treatment. — If  the  deformity  is  one  of  position  rather  than 

369 


370 


SURGICAL   DISEASES    OF   CHILDREN 


Fig.  134.  Malformation  of  ear,  jaw, 
AND  MOUTH.  Side  view.  Case  of  Dr. 
J.  M.  Moore. 


size  of  the  ear  and  the  patient  an  infant  or  quite  a  young  child, 
the  condition  may  be  improved  by  the  use  of  an  ear  truss,  singly 
or  in  pairs,  applied  with  a  spring  or  by  a  bandage  or  a  cap  of  thin 
netting.    If  entirely  too  large,  the  size  of  the  pinna  may  be  reduced 

by  excising  a  portion  of 
triangular  shape,  with  sides 
of  equal  length  with  the 
apex  toward  the  meatus, 
neatly  closing  the  gap  by 
suturing  the  cut  margins 
together. 

To  turn  the  ear  back- 
ward so  that  it  will  lie 
more  closely  to  the  head, 
an  oval  portion  of  skin 
longest  vertically  may  be 
removed  from  the  ear  on 
its  posterior  surface,  a  ver- 
tical groove  cut  in  the  car- 
tilage in  the  center  of  the 
denuded  portion,  the  ear 
folded  back  upon  itself,  and  cut  edges  of  skin  sutured  together  and 
the  raw  surfaces  maintained  in  apposition  until  union  takes  place. 
Or  a  portion,  the  half  of  an 
ellipse,  of  skin  and  its  tmder- 
lying  cartilage  may  be  re- 
moved from  the  ear  poste- 
riorly, and  a  similar  area,  a 
half  ellipse,  denuded  of  in- 
tegument over  the  mastoid 
process  and  the  pinna  sutured 
back  in  proper  position  with 
relation  to  the  head. 


FISTULA  IN  AURIS 
CONGENITA 

This  is  an  opening  in  front 
of  or  just  below  the  tragus, 
which  leads  into  a  blind  canal, 
filled  with  sebaceous  material 
and  sometimes  pus.  If  the 
secretion  accumulates  it  may 

become  hardened.  The  canal  may  sometimes  be  obliterated  by 
swabbing  it  out  with  a  caustic  to  excite  inflammation  and  adhesion 
of  its  walls ;  but  a  better  method  is  to  dissect  out  its  epithelial  lining 
and  bring  the  walls  together  to  heal  by  first  intention. 


Fig.  135  Same  case  as  Fig.  134.  Front 
view.  Malformation  of  ear,  jaw  and 
mouth.     Case  of  Dr.  J.  M.  Moore. 


DEFORMITIES    AND    DISEASES    OF   THE    EAR  371 


COMMON    AFFECTIONS    OF    THE    EXTERNAL    EAR 

Common  affections  of  the  external  ear  are  eczema,  which 
most  frequently  attacks  the  crease  between  the  ear  and  the  head, 
resembling  eczema  intertrigo;  chilblains  upon  the  outer  and  upper 
edge  of  the  ear ;  and  lupus  or  other  form  of  skin  tuberculosis  often 
upon  the  lobule.  Herpes  and  sunburn  should  be  mentioned.  Nevus, 
fibroma,  papilloma  or  sarcoma  or  keloid  may  be  found  upon  the 
auricle.  Traumatic  hematoma  may  occur.  These  present  nothing 
peculiar  in  childhood  and  are  treated  as  the  same  affections  would 
be  upon  any  other  part  of  the  body. 

THE   MEATUS   AUDITORIUS   EXTERNUS 

Anatomy. — It  is  usual  to  consider  that  the  external  auditory 
canal  in  the  adult  is  two-thirds  osseous,  and  in  one-third  of  its  length, 
cartilaginous.  In  the  new-born  infant  the  proportions  are  very 
different,  for  only  the  roof  of  the  inner  third,  which  is  formed  from 
the  squamous  part  of  the  temporal  bone,  with  the  annulus  tym- 
panicus,  are  osseous.  From  the  annulus  the  fibrous  membrane  con- 
taining several  pieces  of  cartilage  extends  outward,  forming  the  re- 
mainder of  the  floor  of  the  meatus,  which  later,  when  ossified,  will 
become  the  tympanic  plate.  The  external  auditory  meatus  is  as  long 
as,  or  even  longer  than,  that  of  the  adult,  in  proportion.  (Syming- 
ton.) Doubtless  the  impression  of  its  being  short  was  taken  from 
examination  of  the  skull  alone,  the  membranous  portion  being  absent. 
Ballantyne  found  that  the  upper  wall  of  the  meatus  measured  19 
mms.  in  length,  and  the  floor,  21  mms.,  the  difference  being  due 
to  the  oblique  position  of  the  membrani  tympani.  In  infants  the 
external  canal  is  inclined  downward  as  it  passes  inward  to  the 
tympanic  membrane,  w^hich  causes  it  to  be  placed  quite  obliquely 
with  relation  to  the  tympanum  as  compared  with  the  adult.  This 
has  given  the  impression  that  the  tympanum  in  the  infant  and 
young  child  is  placed  almost,  if  not  quite,  horizontally,  which  is 
not  the  case.  It  is  true  that  it  is  quite  oblique,  and  especially  so 
with  reference  to  the  downward  sloping  meatus,  but  Ballantyne 
found  it  at  an  angle  of  12  degrees  with  the  floor  of  the  meatus  and 
of  33  degrees  with  the  horizon.  The  normal  angle  with  the  meatal 
floor  in  the  adult  is  said  to  be  45  degrees.  This  position  of  the 
canal,  like  its  cartilaginous  condition  and  other  peculiarities  of  the 
infant,  changes  only  gradually  through  infancy  and  childhood  and 
will  be  found  in  any  stage  of  development  between  the  infantile 
and  the  adult  types.  The  inner  end  of  the  meatus — that  is,  its 
sinus,  in  proximity  to  the  tympanum — is  a  little  larger  than  the 
rest  of  the  canal.    The  narrowest  portion  of  the  canal  is  about  the 


372  SURGICAL   DISEASES    OF    CHILDREN 

joining  of  the  bony  and  the  cartilaginous  portions,  at  the  junction 
of  the  inner  and  middle  thirds,  or  toward  the  middle  of  the  canal. 

Congenital  Occlusion  of  the  Meatus. — The  external  orifice 
of  the  auditory  canal  may  be  closed  by  a  septum,  or  in  other  cases 
there  may  be  no  auditory  canal.  This  deformity  may  exist  either 
with  or  without  any  other  abnormal  development  of  the  external,  or 
any  of  the  middle  or  internal  ear.  But  the  internal  malformation 
is,  as  a  rule,  more  marked,  and  serious  than  that  which  appears 
externally. 

Treatment. — Cases  of  this  kind  cause  parents  great  anxiety, 
and  sometimes  impatience,  but  nothing  remedial  should  be  at- 
tempted before  the  child  is  old  enough  to  have  the  hearing  tested. 
By  the  tuning  fork  and  other  tests  the  condition  of  the  internal 
mechanism  of  hearing  can  be  ascertained.  Earlier  interference  is 
only  necessary  in  case  a  septum  closes  the  canal,  in  which  cerumen, 
or,  in  case  of  inflammation,  pus,  accumulates  and  must  be  released 
by  division  of  the  septum.  If  nothing  of  this  kind  occurs,  an 
exploratory  dissection  may  be  carefully  made  in  the  direction  of 
the  canal.  Or  the  canal  may  be  searched  for  by  a  dissection  behind 
the  ear,  and,  when  found,  .explored  with  a  bent  probe.  If  its 
external  end  be  within  reach  the  meatus  may  be  opened,  but  it  is 
very  difficult  to  line  such  a  canal  with  integument  if  it  is  necessary 
to  dissect  to  any  depth.  In  case  of  absence  of  auricle  and  canal, 
it  is  neither  necessary  nor  possible  to  do  anything  operative  for  its 
correction.  Artificial  ,ears  could  be  worn  if  desired  for  the  sake 
of  appearance.  They  would  be  held  in  place  by  a  spring  passing 
over  the  top  of  the  head  and  hidden  by  the  hair. 

Foreign  Bodies  in  the  Ear  Canal. — A  foreign  body  in  the 
ear  canal  is  so  common  in  children  as  to  deserve  more  than  mention 
as  a  possibility.  The  body  may  be  inanimate  or  animate,  and  con- 
sist of  anything  of  such  size  and  shape  that  it  can  be  introduced  or 
can  get  into  the  canal.  Beads,  buttons,  peas,  beans,  pebbles,  and 
paper  wads  are  usual.  Insects  are  not  so  common,  though  some- 
times found.  Small  beetles,  bedbugs,  fleas,  larvae,  maggots,  or 
woodticks  may  be  discovered  in  the  ear  canal.  One  occasionally 
finds  a  piece  of  onion  which  had  been  heated  and  introduced  by 
the  mother  to  stop  earache,  as  is  a  common  practice  in  parts  of 
Europe  and  among  immigrants  of  that  class  here.  Accumulations 
of  ear  wax  are  not  so  common  as  in  adults. 

Treatment. — If  there  is  much  purulent  discharge  this  must 
be  carefully  wiped  out  with  a  cotton-wrapped  probe  or  applicator 
until  quite  clean.  In  many  cases,  especially  if  there  is  inflamma- 
tion, an  anesthetic  will  be  necessary  for  satisfactory  examination 
or  treatment.  A  head-mirror  and  ear  specula  are  needed.  The 
means  for  removal  will  depend  on  the  shape  and  substance  of  the 


DEFORMITIES    AND    DISEASES    OF   THE    EAR  373 

foreign  body.  Live  insects  are  usually  readily  killed  with  a  few 
drops  of  olive  oil  or  castor  oil,  after  which  they  can  be  syringed 
out.  Maggots  are  best  attacked  with  chloroform  vapor.  Peas, 
beans,  paper  w'ads  or  any  substance  likely  to  swell  by  absorption 
of  moisture  should  not  be  treated  by  syringing.  Some  objects  can 
be  readily  seized  with  small  forceps.  Others  are  better  managed 
by  passing  around  them  a  loop  of  small,  strong  wire.  A  blunt 
hook,  not  too  much  curved,  is  one  of  the  most  convenient  instru- 
ments that  can  be  used  in  many  cases.  The  hook  is  slipped  over  or 
around  the  foreign  body,  w^hich  is  gradually  pulled  out.  Beads 
and  impervious  bodies  may  often  be  forced  out  by  directing  a  cur- 
rent of  w-ater  from  a  syringe  over  and  behind  them.  Dried  ear 
wax  is  best  removed  in  the  sam,e  manner,  after  making  a  small 
opening  between  the  accumulation  and  the  upper  wall  of  the  canal, 
by  which  the  water  may  get  behind.  For  bodies  of  such  shape  and 
substance  as  cannot  be  seized  or  surrounded,  a  camel's-hair  brush, 
dipped  in  glue,  may  be  used.  The  brush  is  spread  in  contact  wath 
the  object  and  left  there  till  the  glue  hardens,  when  they  may  both 
be  withdrawn. 

Diffused  Inflammation  of  the  External  Meatus. — This 
inflammation  may  arise  in  traumatism,  such  as  a  blow,  or  the  pres- 
ence of  a  foreign  body  or  efforts  at  its  removal,  by  the  use  of  irritat- 
ing medicaments,  by  excoriation  of  the  skin  lining  the  meatus,  by 
infection  either  w-ith  or  without  a  wound.  Infection  may  be  intro- 
duced from  outside  or  b}'  way  of  the  middle  ear. 

Symptoms. — The  symptoms  are  those  of  inflammation,  con- 
fined mostly  to  the  lining  of  the  bony  portion  of  the  canal.  Pain 
is  present  and  is  aggravated  by  movements  of  the  jaw.  There  may 
be  tinnitus  or  impairment  of  hearing,  or  dizziness.  After  a  few 
days  the  inflamed  skin  exudes  a  tenacious  sero-ceruminous  material. 
Sometimes  the  skin  itself  exfoliates.  The  disease  runs  its  course  in 
three  or  four  days,  and  usually  results  in  recovery.  In  rare  cases 
the  inflammation  may  cause  ulceration,  or  may  penetrate  to  the 
periosteum  and  be  greatly  prolonged,  and  possibly  result  in  partial 
stenosis  from  cicatricial  contraction  or  hyperostosis. 

Treatment. — The  discharges  should  be  carefulh^  removed  from 
the  canal  by  absorbent  cotton,  wound  upon  an  applicator.  The 
canal  should  be  disinfected  with  hydrogen  peroxide,  applied  with  a 
cotton  swab.  A  few  drops  of  a  solution  composed  of  glycerine,  75 
per  cent. ;  water,  20  per  cent.,  and  carbolic  acid,  5  per  cent.,  should 
be  instilled  into  the  ear  three  or  four  times  a  day.  A  pledget  of 
cotton  closes  the  canal.  Leeches  in  front  of  or  below  or  behind  the 
ear  are  advised  and  are  useful,  although  not  very  often  used  in  chil- 
dren. Dry  heat  or  cold,  usually  cold,  are  used,  and  usually  the  one 
most  grateful  to  the  patient  is  the  most  beneficial. 


374  SURGICAL   DISEASES    OF   CHILDREN 

DIPHTHERITIC  INFLAMMATION  OF  THE  EAR 

Diphtheria  and  pseudo-diphtheria  may  attack  the  ear  either  by 
infection  from  the  outside  or  by  way  of  the  middle  ear.  For  the 
characteristics  of  this  disease  and  the  treatment  see  Section  on 
Diphtheria. 

INJURIES  OF  THE  TYMPANIC  MEMBRANE 

The  tympanic  membrane  may  be  injured  by  accidentally  thrust- 
ing any  slender  object,  such  as  a  pencil  or  wire,  into  the  canal;  or 
in  attempts  to  remove  ear  wax  or  a  foreign  body  with  a  hairpin, 
match,  stick,  toothpick  or  the  like;  or  by  accidental  scalding  with 
a  hot  fluid,  or  cauterizing  by  liniments  or  other  drops  injudiciously 
employed  for  earache ;  or  by  sneezing ;  or  violent  efforts  at  inflat- 
ing the  ears ;  or  by  a  kiss  upon  the  ear ;  by  a  box  upon  the  ear 
with  the  hand  or  a  book;  by  concussion  produced  by  an  explosion; 
by  fracture  of  the  bony  canal,  etc. 

Symptoms  and  Diagnosis. — Pain  may  be  present  at  the  time  of 
injury;  or  it  may  not  be  complained  of  until  inflammation  sets  in. 
Hemorrhage  often  follows  the  injury.  Tinnitus  is  usual,  and  loud 
at  first,  afterward  subsiding.  There  is  usually  deafness  in  some 
degree ;  and,  on  the  contrary,  in  rare  instances  the  hearing  becomes 
painfully  acute.  Shock,  nausea,  giddiness,  and  loss  of  equilibrium, 
and  even  convulsions  occur  when  the  labyrinth  is  injured. 

Examination  may  reveal  rupture  of  the  membrane,  which  is 
most  apt  to  be  located  in  the  posterior-inferior  quadrant.  The  open- 
ing may  be  slit-like  or  ragged  or  a  round  perforation.  The  whole 
membrane  may  be  ecchymotic.  If  there  is  fracture  through  the 
petrous  portion  of  the  temporal  bone  or  the  wound  opens  the 
labyrinth,  cerebro-spinal  fluid  will  escape. 

Prognosis. — In  ordinary  cases  of  rupture  of  the  membrane  the 
prognosis  is  good.  If  the  ossicles,  also,  are  injured,  permanent  im- 
pairment of  the  hearing  may  result.  Injury  severe  enough  to  cause 
discharge  of  cerebro-spinal  fluid  is  very  serious.  If  suppuration 
ensue  the  prognosis  is  very  grave.  If  the  labyrinth  is  injured  it 
will  take  several  weeks  to  determine  the  result  to  the  hearing.  In 
the  meantime  the  nausea  and  giddiness  may  persist. 

Treatment. — Usually  there  is  little  to  be  done  locally  except 
to  prevent  infection  by  wiping  the  ear  out  carefully,  and  plugging 
the  meatus  with  dry  sterile  cotton  to  prevent  the  entrance  of  germs. 
If  symptoms  of  inflammation  ensue,  leeching  is  in  order,  and  tlie 
antiseptic  line  of  treatment  prescribed  for  diffused  inflammation 
of  the  external  meatus. 


DEFORMITIES   AND   DISEASES   OF  THE  EAR  37s 

MYRINGITIS,  INFLAMMATION  OF  THE  TYMPANIC  MEM- 
BRANE 

This  may  be  due  to  any  of  the  causes  enumerated  as  likely  to 
injure  the  membrane  itself,  or  the  inflammation  may  extend  to  the 
membrane  from  an  inflamed  meatus  or  tympanic  cavity. 

Symptoms  and  Diagnosis. — The  most  marked  symptom  is  pain, 
but  tinnitus  and  some  deafness  are  usually  present  when  swelling 
occurs.  Deafness  is  only  slight,  unless  the  middle  ear  is  involved, 
when  it  is  greater.  Slight  fever  may  be  present.  On  ocular  exam- 
ination the  membrane  is  found  to  be  congested,  which  gives  it  a 
reddened  or  yellowish-red  color.  The  part  worst  affected  is  along 
the  handle  of  the  malleus  and  upper  half  of  the  membrane.  Swell- 
ing and  infiltration  of  the  membrane  extending  on  to  the  wall  of 
the  canal  may  render  their  line  of  junction  indistinguishable.  Small 
blisters,  or  blebs,  may  sometimes  be  seen  upon  the  membrane,  due 
to  exudation  of  serum  between  the  epidermic  and  the  fibrous  layers 
of  the  drum-head.  The  contents  of  these  blebs  may  become  puru- 
lent, or,  more  rarely,  bloody.  When  myringitis  accompanies  otitis 
media,  the  mucous  and  fibrous  layers  are  most  affected.  With 
otitis  media  there  is  more  marked  bulging  of  the  membrane  into 
the  external  canal. 

Prognosis. — The  prognosis  depends  upon  the  amount  of  altera- 
tion, destructive  or  degenerative,  that  takes  place  in  the  membrane. 
The  acute  may  merge  into  a  chronic  condition.  If  associated  with 
otitis  media,  with  perforation,  or  if  the  patient  is  of  the  strumous 
type  or  has  had  repeated  attacks,  the  prognosis  is  more  serious. 

Treatment. — Usually  a  purgative  is  indicated,  and  later,  salicy- 
lates, or  iodides,  syrup  of  the  iodide  of  iron  and  tonics.  Dry  heat, 
and,  in  obstinate  cases,  hot  irrigation  are  useful.  Some  advise 
cocaine  solution  for  the  pain,  but  its  action  is  uncertain,  especially 
in  children.  The  2  to  5  per  cent,  solution  of  carbolic  acid  in 
glycerine  is  more  certain  and  safer.  The  blisters  which  appear  upon 
the  tympanic  membrane  should  be  pricked.  If  there  is  purplish 
swelling  the  outer  layer  of  the  drum  membrane  should  be  incised 
or  scarified.  If  pus  is  present,  care  should  be  taken  not  to  perfo- 
rate the  inner  layer,  lest  infection  be  introduced  into  the  middle 
ear.  If  the  Eustachian  canal  is  closed  it  should  be  inflated  to  equal- 
ize the  air  pressure.  The  ear  should  be  irrigated  with  a  warm  solu- 
tion of  boracic  acid,  dried  and  closed  with  dry  cotton. 

INFLAMMATION   OF  THE   MIDDLE  EAR     (OTITIS   MEDIA; 

TYMPANITIS) 

The  tympanic  cavity  of  the  infant  differs  from  that  of  the  adult 
in  the  comparatively  open  condition  of  the  petrosquamosal  suture. 


376  SURGICAL   DISEASES    OF    CHILDREN 

The  roof  of  the  cavity  is  formed  by  the  meeting  of  the  squamous 
portion  with  the  petrous  portion  of  the  temporal  bone,  a  shelving 
outgrov^th  of  the  pars  petrosa  superiorly  overlapping  the  pars  squa- 
mosa inferiorly.  But  the  suture  which  joins  them  is  unossified; 
and  there  extends  through  it  a  process  of  connective  tissue  from  the 
dura-mater  which  connects  with  the  mucoperiosteal  lining  of  the 
tympanic  cavity  and  contains  blood-vessels  and  lymphatics.  This 
condition,  as  Symington  long  ago  pointed  out,  increases  the  liability 
of  direct  extension  of  inflammation  from  the  tympanic  cavity  to 
the  membranes  of  the  brain. 

Inflammation  of  the  middle  ear  is  extremely  common  in  infants 
and  children.  It  often  leads  to  consequences  serious  not  only  to 
the  hearing,  but  to  the  life,  and  it  frequently  requires  surgical 
attention.  For  our  present  purpose  it  is  not  necessary  to  discuss 
an  elaborate  or  refined  classification,  for,  from  the  standpoint  of 
practical  clinical  surgery,  all  the  inflammations  of  the  middle  ear 
may  be  considered  under  two  groups :  non-suppurative,  or  catarrhal 
inflammations,  and  suppurative  inflammations. 

The  term  catarrhal  inflammation  does  not  deny  the  presence 
of  infective  micro-organisms.  In  fact,  the  pneumococcus,  the  staph- 
ococcus  and  others  are  often  found  in  the  exudate,  resulting 
from  non-suppurative  inflammation.  In  such  cases  either  the  or- 
ganism is  not  active  or  the  system  of  the  patient  is  resistant.  Again, 
cases  of  suppurative  otitis  occur  in  which  no  micro-organisms  can 
be  found.  The  diflrerences  between  the  two  groups  of  cases  are 
greater  in  degree  than  in  kind.  The  catarrhal  may  readily  merge 
into  or  be  followed  by  the  suppurative  form  of  the  disease. 

It  is  best  to  look  upon  all  cases  of  inflammation  of  the  middle 
ear  as  due  to  infection  by  micro-organisms ;  although  it  is  true 
that  there  may  be  an  underlying  or  predisposing  dyscrasia.  The 
patient  may  be  undoubtedly  rheumatic  or  strumous,  or  undeniably 
syphilitic  or  tuberculous.  Any  disease  of  the  Eustachian  tubes 
which  interferes  with  the  equilibrium  of  the  air-pressure  inside  of 
and  outside  of  the  tympanum  predisposes  to  otitis.  With  occlusion 
of  the  tube,  absorption  of  the  oxygen  of  the  imprisoned  air  reduces 
its  bulk,  and  the  diminished  intra-aural  pressure  leads  to  engorge- 
ment of  the  blood-  and  lymph-vessels.  The  occlusion  also  causes 
retention  of  the  secretions.  In  the  larger  number  of  cases  the 
catarrhal  tympanitis  is  associated  with  rhinitis,  naso-pharyngitis 
and  inflammation  of  the  Eustachian  tubes,  adenoid  growths,  en- 
larged tonsils  or  hypertrophied  turbinates,  especially  the  middle 
turbinate,  spurs  and  deflections  of  the  septum,  and  may  thus  be 
said  to  be  secondary  to  a  pre-existing  disease.  A  primary  attack, 
or  the  onset  of  secondary  symptoms,  is  usually  attributed  to  taking 
cold,  to  cold  bathing  or  sea  bathing,  cold  wind  or  the  like,  and 


DEFORMITIES    AND    DISEASES    OF   THE   EAR  377 

there  may  be  a  clear  history  of  exposure.  In  rarer  instances  it 
may  originate  in  traumatism,  such  as  a  box  on  the  ear,  or  acci- 
dental puncture  of  the  ear-drum,  violent  sneezing  from  rhinitis, 
or  the  passage  of  vomited  matters,  or  even  worms  into  the  middle 
ear  through  the  Eustachian  tube.  If  there  be  added  to  any  of  these 
causes  active  infective  agents  or  a  low  state  of  the  vital  resistance, 
suppurative  inflammation  will  result,  either  by  transmission  of 
infective  material  along  the  lumen  of  the  Eustachian  tube,  or  by 
way  of  the  blood,  or  through  the  external  ear,  or,  more  commonly,  it 
is  thought,  through  lymphatic  channels  connecting  the  naso-pharynx 
and  middle  ear.  The  germs  most  apt  to  act  as  etiological  factors  in 
suppurative  otitis  are  the  pneumococcus,  the  streptococcus  pyogenes, 
the  staphylococcus  pyogenes  albus  and  aureus,  the  bacillus  pneu- 
moniae of  Friedlander,  the  germs  of  scarlatina,  measles,  influenza ; 
or,  less  frequently,  the  diphtheria  bacillus,  the  tubercle  bacillus,  the 
colon  bacillus,  the  bacillus  pyogenes  fetidus,  or  even  the  gonococcus. 

In  acute  catarrhal  otitis  media  of  the  membrane  lining  the  tym- 
panic cavity  is  swollen  by  congestion  of  the  blood-vessels  and  fill- 
ing of  the  intercellular  spaces  with  serum.  The  goblet  c-ells  of  the 
mucosa  undergo  rapid  mucoid  degeneration,  and  these,  with  serum, 
are  poured  out  in  greater  or  less  quantity,  forming  the  character- 
istic mucous  exudate.  The  surface  of  the  mucous  membrane  thus 
becomes  partially  denuded  of  its  epithelium.  The  process  does  not 
lead  to  any  great  destructive  changes,  although  in  rare  instances 
the  drum-head  may  be  perforated.  The  morbid  process  runs  its 
course  in  a  few  days.  The  mucous  membrane  is  soon  restored  to 
its  usual  condition,  excepting  that  it  is  more  susceptible  than  before 
to  inflammation,  which  may  recur  or  become  chronic. 

In  the  presence  of  active  infection  there  is  proliferation  of 
leucocytes,  abscess  formation,  with  perforation,  or  perhaps  de- 
struction of  the  drum-head,  exfoliation  of  one  or  more  of  the  ossi- 
cles ;  or  it  may  be  with  mastoiditis,  bone  necrosis,  thrombosis  or 
phlebitis  of  the  adjacent  sinuses,  lepto-  or  pachymeningitis,  cerebral 
abscess,  facial  paralysis,  disease  of  the  internal  ear  with  labyrinthine 
deafness,  or  extension  to  the  temporo-maxillary  joint,  causing 
ankylosis. 

Symptoms  and  Diagnosis. — It  may  be  impossible  to  differ- 
entiate between  acute  non-suppurative  and  acute  suppurative  otitis 
media.  In  infants  the  symptoms  may  be  very  obscure,  there  being 
nothing  objective  but  fever  and  no  diagnosis  made  unless  the  ear 
drum-heads  be  examined,  untij  rupture  occurs,  with  discharge  of 
mucus  or  mucopus,  followed  by  fall  in  the  temperature.  But 
there  is  usually  evidence  of  pain,  such  as  more  or  less  continuous 
crying,  wakefulness  and  restlessness,  and  sometimes  rolling  the 
head  or  beating  the  head  with  the  hands  or  pulling  at  the  cars. 


378  SURGICAL   DISEASES    OF   CHILDREN 

In  older  children  there  is  fever,  great  restlessness,  more  rarely 
delirium  or  convulsions,  while  pain,  deafness  or  noises  in  the  ears 
are  commonly  complained  of.  Occasional  symptoms  are  cough  not 
otherwise  accounted  for,  and  vomiting.  Examination  may  reveal 
tenderness  on  pressure  over  the  tragus,  and  sometimes  over  the 
mastoid  or  the  styloid  processes ;  but  pain  or  tenderness  over 
the  mastoid  or  below  the  ear  or  in  the  post-auricular  lymphatics  does 
not  necessarily  indicate  suppuration  of  the  antrum  and  mastoid 
cells.  The  tympanum  may  appear  reddened  or  lusterless,  or,  after 
a  short  time  has  elapsed,  it  may  bulge  noticeably  with  the  accumu- 
lated mucus  or  pus  behind  it.  Bulging  of  the  ear-drum  may  also 
be  due  to  hemorrhage  behind  it,  as  might  occur  from  traumatism, 
or  in  cerebro-spinal  meningitis,  or  in  hemophilia,  scorbutus,  Hodg- 
kin's  disease,  pernicious  anemia,  or  purpura  hemorrhagica.  But 
any  of  these  are  far  more  uncommon  than  otitis  media,  and  usually 
are  accompanied  by  a  characteristic  train  of  symptoms.  Either 
one  or  both  ears  may  be  involved  in  the  otitis,  simultaneously  or 
successively.  If  unrelieved  in  a  few  hours  to  a  few  days,  depend- 
ing on  the  virulence  of  the  inflammation,  rupture  of  the  tympanic 
membrane  may  occur,  with  subsidence  of  the  symptoms.  The  open- 
ing in  the  tympanic  membrane  is  usually  round  or  oval  or  elliptical, 
and  is  most  frequently  located  in  the  posterior-inferior  quadrant. 

The  continuation  of  fever  and  nervous  symptoms  after  the 
tympanic  membrane  has  ruptured,  or  been  opened  and  discharged, 
is  indicative  of  insufficient  drainage,  or  possibly  of  farther  exten- 
sion of  the  inflammation. 

Malodorous  discharge  usually  indicates  implication  of  the  ossi- 
cles or  osseous  walls.  Continued  or  irregular  fever,  with  tender- 
ness over  the  mastoid,  indicates  probable  extension  into  the  mastoid 
antrum  and  cells.  Long  continuation  of  a  profuse  discharge  indi- 
cates disease  of  a  chronic  nature.  The  intracranial  complications 
do  not  occur  in  the  catarrhal  cases  of  otitis,  but  in  the  suppurative ; 
and  most  frequently  in  the  suppurative  cases  which  have  become 
chronic.  Otitis  should  always  be  thought  of  in  the  diagnosis  of 
any  fever  of  obscure  origin,  or  in  acute  exacerbations  during  any 
of  the  anginas  or  infections  or  exanthemata  with  which  it  is  so 
frequently  associated,  not  forgetting  the  intestinal  infections.  Scar- 
let fever  and  measles  are  the  most  frequently  of  all  associated  with 
otitis,  Which  becomes  chronic  and  leads  to  serious  intracranial 
disease.  An  acute  suppurative  otitis  media  without  pain  should  be 
very  carefully  examined  for  tuberculosis,  which  is  probably  at  the 
bottom  of  it. 

Prognosis. — On  account  of  the  many  possible  complications 
and  sequellse,  the  prognosis  is  somewhat  uncertain.  Yet  the  great 
majority  of  cases  recover,  and  this  without  even  any  permanent 


DEFORMITIES   AND   DISEASES   OF   THE   EAR  379 

impairment  of  hearing ;  or  there  may  be  impairment  of  hearing 
from  ankylosis  of  the  ossicles  or  adhesions  between  the  ossicles  or 
between  the  drum-head  and  the  walls  of  the  cavum  tympani,  and  a 
liability  to  a  repetition  of  the  attack.  Or  the  case  may  lead  to  one 
or  more  of  the  complications  before  mentioned,  or  it  may  assume 
a  chronic  form,  with  masses  of  granulation  tissue,  and  sometimes 
polypi  growing  upon  the  walls  of  the  tympanic  cavity,  and  a  per- 
sistent vile-smelling  discharge.  If  the  discharge  contains  only  mu- 
cus the  prognosis  is  much  better  than  if  it  contains  pus.  Lessening 
of  discharge,  with  improvement  of  the  hearing  and  absence  of 
fever,  indicates  favorable  progress.  A  streptococcus  infection  or 
a  mixed  infection  occurring  during  or  following  one  of  the  spe- 
cific fevers  is  apt  to  be  more  obstinate. 

Treatment. — Prophylactic  treatment  should  always  be  em- 
ployed. It  consists  of  careful  treatment  of  nose  and  throat  in  all 
anginas  and  infectious  diseases  apt  to  be  followed  by  otitis.  At  the 
outset  of  the  disease,  general  and  local  depletion  are  useful — the 
former  attained  by  purgation  and  the  latter  by  warm  baths — espe- 
cially to  the  lower  extremities,  and  by  warmth  externally  over  the 
ear.  Leeches  applied  near  the  tragus  or  beneath  the  auricle,  or 
perhaps  best  of  all,  over  the  mastoid  antrum  or  at  the  tip  of  the 
mastoid  process,  are  useful  in  sthenic  children,  although  at  present 
they  are  little  employed.  An  effort  should  be  made  to  restore  the 
normal  intratympanic  air  pressure  by  Politzerization  or  Eustachian 
catheterization  or  suction  with  the  Siegel  otoscope.  As  a  preliminary 
step  the  naso-pharynx  should  be  carefully  cleansed,  and  any  inflam- 
matory or  obstructive  condition  located  there  should  be  treated. 
Pain  may  be  relieved  by  heat,  either  dry  or  moist.  Dry  heat  is 
most  recommended  in  the  beginning  of  the  attack.  It  is  applied  by 
a  bag  or  coil  of  hot  water,  or  a  bag  of  hot  salt,  sand  or  hops,  or 
an  electric  heater  or  a  Japanese  hot  box.  Moist  heat  may  be  used 
by  filling  the  external  canal  with  warm  sterile  water  while  the 
patient  lies  on  the  opposite  side,  and  then  applying  a  hot  water 
bag  over  the  ear  to  keep  the  column  of  water  in  the  canal  hot. 
But  the  best  means  of  using  heat,  if  the  pain  and  inflammation 
persist,  is  by  a  fountain  syringe  and  a  solution  of  boric  acid,  or 
of  mercuric  bichloride,  I  to  5000.  The  water,  as  hot  as  can  be 
borne  and  under  very  little  pressure,  should  flow  into  and  out  of 
the  ear  canal  for  five  to  fifteen  minutes  at  a  time.  This  may  be 
repeated  every  few  hours,  or  if  the  pain  returns.  After  each  irri- 
gation the  canal  should  be  dried  with  absorbent  cotton  wound  upon 
an  applicator,  and  then  lightly  stopped  with  a  pledget  of  cotton 
to  keep  out  infective  organisms.  The  domestic  use  of  oils,  lotions, 
etc.,  in  the  ear,  and  of  poultices  and  other  household  applications 
upon  the   outside  is  usually  either   useless  or   injurious.     A   few 


38o  SURGICAL   DISEASES    OF   CHILDREN 

drops  of  a  2  to  5  per  cent,  solution  of  carbolic  acid  in  glycerine, 
diluted  one-fifth  with  water,  should  be  instilled  into  the  ear  sev- 
eral times  a  day.  This  has  an  excellent  effect  as  an  antiseptic  and 
analgesic.  It  also  moistens  the  inflamed  tympanum,  which  is  very 
soothing,  and  it  relieves  the  engorgement  of  the  tissues  by  promot- 
ing exudation.  It  may  be  necessary,  also,  to  administer  codeine  or 
other  opiate  if  the  pain  is  too  severe. 

INCISION   OF  THE  MEMBRANA  TYMPANI  (MYRINGOTOMY) 

If'  the  inflammation  does  not  subside  under  this  treatment,  or 
the  collection  of  exudate  in  the  tympanic  cavity  is  excessive,  it  is 
advisable  to  incise  the  drum-head.  The  drum-heads  should  always 
be  examined  with  a  good  light,  head  mirror  and  ear  speculum.  If 
there  is  bulging  of  the  membrane,  showing  pressure  from  within, 
an  incision  should  be  made.  In  fact,  it  is  not  always  well  to  wait 
for  bulging  of  the  membrane,  but  if  it  is  excessively  inflamed,  as 
indicated  by  its  red  color,  swelling  and  loss  of  luster,  it  is  treated 

as  one  would  a  cellulitis  with  excessive 
tension  elsewhere;  namely,  by  incision. 
Paracentesis — that  is,  a  mere  puncture — ■ 
is  no  longer  in  favor.  It  does  not  afford 
adequate  drainage  to  the  cavity,  nor  re- 
lieve the  tension  of  the  membrane  itself. 
Incision,  while  apparently  more  radical, 
is     really     conservative     treatment.      The 

-r^  .J  incised  wound  heals  readilv,  leaving  very 

Fig.  136.     Line  of  in-  ,.    ,  ,  .         .       -  r   r        ^• 

cisioN  OF  THE  MEMBRANA  little  scar  aud  no  impairment  of  function 

TYMPANI  FOR  THE  EVAcu-  as  a  rcsult  of  thc  incision.     There  is  far 

PRODUCES. '''^'^^''''''''°^''  ^ess  danger  of  making  an  unnecessary 
or  premature  incision  than  there  is  of 
postponing  until  greater  damage  is  done.  Special  instruments,  or 
myringotomes,  are  made  for  this  little  operation,  but  a  fine  tenotome 
with  a  long,  slender  shank,  or  a  narrow  bistoury  will  answer  the 
purpose.  A  general  anesthetic  is  usually  necessary  with  children. 
A  good  light  upon  the  drum-head  should  be  obtained,  and  the 
child's  head  steadied  by  an  assistant.  A  semi-circular  incision  is 
made  in  the  two  posterior  quadrants.  Beginning  about  half  way 
between  the  tip  of  the  handle  of  the  malleus  and  the  inferior  mar- 
gin of  the  drum-head,  the  incision  curves  backward  and  upward 
and  passes  about  half  way  between  the  tip  and  the  posterior  margin, 
and  thence  more  directly  upward  toward  the  margin,  as  shown 
by  the  black  line  in  Fig.  136.  Some  surgeons  carry  the  incision 
through  the  superior  margin  of  the  membrana  tympani  and  into 
the  wall  of  the  meatus,  as  shown  in  the  dotted  line.  The  point  of 
the  knife  should  not  be  thrust  deeper  than  necessary  to  penetrate 


DEFORMITIES    AND    DISEASES    OF   THE   EAR  381 

the  drum-head,  lest  the  wall  of  the  tympanic  cavity,  which  is  not 
far  behind  it,  be  injured.  If  there  is  bulging  confined  to  Shrapnel's 
membrane,  the  upper  posterior  quadrant,  it  indicates  suppuration 
in  the  attic  and  the  incision  is  best  made  where  it  bulges  most. 
After  incision,  irrigation  with  warm  boric  acid  solution  or  mer- 
curic bichloride,  i  to  5000,  cleanses  the  ear.  If  the  discharge  is 
very  tenacious  a  solution  of  sodium  bicarbonate  or  other  sterile 
alkaline  solution  hastens  the  flow.  Irrigation  may  be  practical 
once  or  several  times  a  day,  according  to  the  amount  of  the  dis- 
charge, but  enough  to  keep  the  ear  thoroughly  cleansed.  But  when 
thorough  cleaning  can  be  secured  by  dry  mopping  with  pledgets 
of  absorbent  cotton,  this  method  is  preferable,  especially  when 
the  discharge  shows  a  tendency  to  diminish.  It  is  possible  to 
perpetuate  a  discharge  by  injudicious  syringing.  After  each  irri- 
gation the  canal  should  be  carefully  dried  with  pledgets  of  cotton 
on  an  applicator,  and,  if  there  is  no  tenderness,  finely-powdered 
boracic  acid  should  be  dusted  in  and  the  meatus  lightly  plugged 
with  cotton. 

After  the  tenderness,  pain,  and  acute  inflammatory  symptoms 
have  subsided,  Eustachian  inflation  should  be  used.  Some  sur- 
geons now  prefer  suction  by  the  Siegle  otoscope  as  better  and 
safer.  The  Eustachian  tube  would  be  very  easily  catheterized  in 
a  child  but  for  the  patient's  fear  and  restlessness. 

If  the  discharge  persists  for  more  than  two  or  three  weeks 
the  ear  may  be  mopped  with  a  2^  per  cent,  solution  of  carbolic 
acid,  or  a  10  per  cent,  solution  of  argyrol,  or  a  25  per  cent,  solution 
of  hydrogen  peroxide  in  water,  and  then  carefully  wiped  out  before 
insufflation  with  the  powder.  This  treatment  will  subdue  the  sup- 
puration and  keep  down  the  exuberant  granulations  which  are 
apt  to  form.  Catarrhal  cases  get  well  more  promptly,  but  a  sup- 
purative case  may  require  proper  attention  and  perhaps  daily  inspec- 
tion for  five  or  six  weeks  to  secure  the  best  result  and  prevent  its 
drifting  into  a  chronic  condition.  Complications  by  mastoiditis, 
meningitis  or  implication  of  the  sinuses  will  be  considered  in  other 
sections. 

As  before  stated,  in  the  majority  of  acute  cases  in  which  the 
membrana  tympani  is  opened  with  a  knife,  or  even  spontaneously, 
it  heals  again  promptly.  In  fact,  it  may  reunite  before  the  cavity 
has  drained  sufificiently,  and  require  reopening.  In  cases  which  be- 
come chronic  the  perforation  sometimes  remains  permanently  open 
and  discharge  continues  or  recurs  at  intervals ;  and  the  cavity  may 
be  filled  with  granulations.  In  such  cases  it  may  be  necessary  to 
scrape  away  the  exuberant  granulations,  but  usually  they  disappear 
under  mopping  with  the  carbolic  or  argyrol  or  peroxide  solutions 
and  dusting  with  boric  acid.     If  the  soft  granulations  persist,  pure 


382  SURGICAL   DISEASES    OF   CHILDREN 

alcohol,  eight  to  ten  drops  in  the  ear  once  or  twice  a  day  or  once 
in  two  days,  with  dry  cleansing  and  dusting  in  the  intervals,  may 
be  successful.  Some  recommend  very  strong  solutions  of  silver 
nitrate  in  extremely  obstinate  cases.  Another  method  of  dealing 
with  the  granulations  is  to  touch  them  with  as  much  deliquesced 
chromic  acid  as  will  cling  to  the  end  of  a  bare  metal  probe  or 
applicator. 

When  this  granulating  condition  has  become  subacute  or 
chronic,  polypi  are  apt  to  form.  The  polypi  should  be  twisted  off 
at  the  pedicle  by  a  probe  or  fine  forceps,  or  removed  with  a  wire 
snare,  and  the  stump  touched  with  chromic  acid. 

MASTOIDITIS 

The  cells  of  the  mastoid  portion  of  the  temporal  bone  are 
not  fully  developed  until  after  puberty.  But  the  mastoid  antrum 
is  present  even  in  infancy.  The  antrum  communicates  with  the 
cavity  of  the  tympanum,  and  its  thin  walls  and  very  thin  roof  form 
but  a  slight  barrier  between  the  pneumatic  cavity  of  the  temporal 
bone  and  the  membranes  of  the  brain.  With  further  development 
the  walls,  and  especially  the  roof,  of  the  antrum  become  thicker,, 
and  about  the  period  of  puberty  they  contain  the  vacuolations  or 
cells  known  as  the  mastoid  cells. 

Mastoiditis,  inflammation  of  the  mastoid  antrum  and  cells, 
one  or  both,  is  one  of  the  most  common  and  most  serious  diseases 
located  about  the  head.  It  seldom  occurs  as  a  primary  disease, 
but  usually  by  extension  of  inflammation  from  adjacent  tissues,  in 
most  instances  spreading  from  the  cavity  of  the  tympanum.  In 
rarer  instances,  infective  inflammation  in  the  posterior  wall  of  the 
external  auditory  meatus  penetrates  to  the  mastoid  antrum  and 
cells,  or  mastoid  periostitis  involves  the  bone  beneath.  The  invad- 
ing organisms  are  those  already  mentioned  as  causing  otitis  media. 
The  mucous  membrane  becomes  inflamed;  the  bone  beneath  it  is 
soon  involved,  softens,  and  breaks  down;  the  destructive  process 
advances  rapidly  in  the  porous  osseous  structure,  and  more  slowly 
in  that  which  is  denser.  As  the  shape  of  the  bone  and  its  degree 
of  development  and  relative  density,  the  virulence  of  the  inflam- 
mation and  the  vital  resistance  to  morbific  influence  vary  greatly 
in  different  patients,  it  is  very  difficult  to  tell  in  which  direction  the 
inflammation  will  extend  most  quickly  or  in  how  many  hours  or 
days  abscess  formation  or  necrosis  wih  occur.  Mastoiditis  does 
not  always  go  on  to  destruction  of  the  mastoid  process,  nor  always 
extend  to  adjoining  tissues.  It  may  be  confined  to  the  antrum  alone 
or  destroy  but  a  small  portion  of  its  bony  wall.  That  most  fre- 
quently involved  is  just  in  front  of  and  below  the  antrum.  Next 
in  frequency  are  involved  the  cells  in  the  tip  of  the  process,  the 


DEFORMITIES    AND    DISEASES    OF   THE    EAR  383 

posterior  border  of  the  process  near  the  sigmoid  sinus,  and  the 
portion  lying  above  the  antrum. 

Symptoms  and  Diagnosis. — The  symptoms  are  pain,  localized 
tenderness,  swelling,  and  fever.  The  pain  varies  greatly  in  degree. 
It  is  located  about  the  ear  or  over  the  whole  side  of  the  head,  and 
it  has  nothing  characteristic  that  is  pathognomonic  of  mastoiditis. 
Tenderness  over  the  region  of  the  mastoid  is  a  more  important 
symptom.  It  should  not  be  confounded  with  tenderness  of  the 
auricle  or  cartilaginous  portion  of  the  canal.  The  greatest  tender- 
ness is  over  the  antrum,  but  the  area  of  tenderness  does  not  indi- 
cate the  position  nor  limit  the  area  of  the  disease.  Swelling  is 
only  present  early  in  those  unusual  cases  of  periosteal  mastoid- 
itis. It  usually  does  not  appear  until  the  inflammatory  process  has 
softened  and  penetrated  the  cortical  layer  of  bone.  The  most  fre- 
quent seat  of  swelling  is  posteriorly  at  the  inner  end  of  the  canal. 
Far  less  frequently  there  is  swelling  and  redness  behind  the  auricle. 
Swelling  and  tenderness  of  the  lymph  nodes,  near  the  insertion  of 
the  sterno-mastoid,  is  often  present  in  mastoiditis,  and  not  present, 
as  a  rule,  in  otitis  media  alone.  It  is  therefore  a  diagnostic  symp- 
tom of  value. 

Fever  is  usually  present,  and  may  vary  from  loi  degrees  or 
102  degrees  to  105  degrees  in  acute  cases.  But  a  case  may  take  a 
subacute  or  chronic  course,  with  scarcely  any  or  only  a  slight  and 
irregular  elevation  of  temperature. 

Otorrhea,  otitis,  or  a  history  of  an  otitis  at  some  previous 
time  should  always  be  considered  in  the  diagnosis. 

A  blood  count  may  aid  in  differentiating  obscure  mastoiditis 
from  typhoid  fever,  influenza,  or  malaria,  since  leucocytosis  is 
indicative  of  the  presence  of  a  suppurative  process  and  is  not  pres- 
ent in  the  diseases  mentioned,  which  sometimes  resemble  mastoiditis. 

Prognosis. — The  prognosis  in  acute  cases  treated  promptly  is 
favorable.  The  inflammation  may  perhaps  be  subdued  without 
suppuration.  Even  in  cases  which  have  gone  on  to  abscess  the 
prognosis  is  favorable  if  proper  treatment  is  carried  out  while  the 
disease  is  still  limited  to  the  mastoid.  Danger  lies  in  the  extension 
of  the  morbid  process  to  near-by  sinuses  or  meninges.  Before 
operation  it  is  impossible  to  determine  exactly  the  location  or  the 
extent  of  the  disease  process,  and  therefore  the  prognosis  is  always 
guarded. 

Treatment. — So  many  cases  of  mastoiditis  take  their  origin  in 
neglected  otitis  media  that  prophylaxis  by  proper  treatment  of  an 
inflammation  of  the  tympanic  cavity,  whether  acute  or  chronic,  is 
a  matter  of  importance. 

While  all  cases  of  inflammation  of  the  mastoid  should  be  looked 
upon  as  infectious,  it  should  not  be  regarded  as  inevitable  that  the 


384  SURGICAL   DISEASES    OF   CHILDREN 

inflammation  should  go  on  to  abscess.  An  attempt  should  be  made 
to  abort  the  process.  Congestion,  and  even  inflammatory  infiltra- 
tion, may  be  subdued,  the  infective  organisms  destroyed,  and  the 
products  of  the  inflammation  removed  before  any  destruction  has 
occurred.  If  the  case  is  acute,  a  warm  bath  and  a  mercurial  and 
saline  purgative  are  in  order.  Following  the  purgative,  the  use  of 
mercury  in  alterative  doses  is  beneficial.  Leeching,  although  a  little 
out  of  fashion  at  the  present  time,  often  shows  not  only  temporary 
relief,  but  permanently  beneficial  effect. 

The  application  of  cold,  by  means  of  the  ice  bag  or  the  coil, 
is  a  powerful  means  of  checking  inflammatory  action.  The  cold 
should  not  be  intense  in  children,  lest  it  have  a  depressant  action, 
local  and  general.  It  should  not  be  used  in  asthenic  cases.  When- 
ever used  it  should  be  moderated  to  a  comfortable  coldness  by 
interposing  a  thickness  or  two  of  flannel  between  the  ice-bag  and 
the  head.  To  do  more  good  than  harm,  the  cold  application,  once 
begun,  should  be  used  continuously  for  one  to  three  days,  and  then 
discontinued  gradually.  Intermittent  use  of  cold  has  an  aggravat- 
ing efifect.  Heat,  as  advised  in  otitis  media,  is  preferred  to  cold 
by  many  surgeons,  and  is  certainly  better  in  asthenic  cases.  In 
cases  involving  the  tympanic  cavity,  and  this  includes  nearly  all 
cases,  the  drum-head  should  be  freely  incised  and  the  upper  and 
posterior  end  of  the  incision  prolonged  through  its  margin  and 
through  the  skin  and  periosteum  to  the  bony  wall  of  the  canal. 

If,  after  several  days  of  this  treatment,  there  is  no  satisfactory 
abatement,  but  the  pain,  fever  and  tenderness  continue,  no  further 
time  should  be  expended  in  this  manner.  Operation  is  indicated. 
Bulging  of  the  canal  upon  its  superior  and  posterior  surface  at 
its  inner  end,  especially  when  incision  through  the  periosteum  in 
this  region  does  not  abate  the  symptoms,  calls  for  the  mastoid 
operation. 

If,  in  the  course  of  mastoiditis,  chills,  vertigo,  nausea,  or 
vomiting  without  nausea,  psychic  excitement,  delirium,  convulsions, 
or  coma  occur,  the  disease  has  invaded  the  lateral  sinus,  the  brain 
or  its  coverings,  and  operative  interference  is  imperative. 

With  fever  and  pain  present,  if  tenderness  and  swelling  de- 
velop behind  the  ear,  independently  of  the  external  canal,  either 
cartilaginous  or  bony,  operation  is  indicated.  If,  in  the  presence 
of  an  otitis  media,  symptoms  arise  pointing  toward  mastoiditis, 
and  it  is  found  that  the  infection  is  streptococcal,  the  probability  of 
mastoid  invasion  becomes  a  certainty  and  the  case  will  likely  require 
operation  sooner  or  later. 

A  pronounced  and  persistent  mastoid  tenderness,  even  in  the 
absence  of  fever  or  discharge,  justifies  an  exploratory  operation. 

Mastoidectomy. — Although   one   expects   to   encounter  pus   in 


DEFORMITIES   AND   DISEASES   OF  THE   EAR  385 

this  operation,  he  should  take  no  chances  on  further  infection  on 
account  of  the  surgical  procedure.  The  field  of  operation,  instru- 
ments, hands,  sponges,  towels,  and  all  that  conies  in  contact  with 
the  wound  should  be  sterilized.  The  head  is  shaved  over  all  space 
within  three  inches  of  the  ear,  and  the  skin  carefully  cleansed 
according  to  rules  already  laid  down.  The  ear  canal  should  be 
previously  cleansed  and  rendered  as  nearly  sterile  as  possible.  The 
instruments  required  for  the  mastoid  operation  are  one  or  two 
scalpels,  hemostats,  a  periosteum  elevator,  retractors  (the  self- 
retaining  retractor  is  convenient),  a  probe,  a  grooved  director, 
gouges  and  mallet  (the  Russian  perforator  is  a  useful  instrument, 
and  gouge  forceps  or  rongeurs  greatly  facilitate  the  removal  of 
bone),  scissors,  and  sharp-edged  spoon-curettes  with  strong  shanks 
and  handles. 

The  incision  through  the  soft  parts  is  curvilinear,  with  the 
convexity  backward.  It  begins  at  a  point  on  a  level  with  or  above 
the  superior  border  of  the  concha  and  curves  downward,  nearly 
parallel  to  and  about  half  an  inch  behind  the  attachment  of  the 
auricle,  to  end  at  or  below  the  tip  of  the  mastoid.  If  it  should 
become  necessary  later  to  secure  more  room,  this  incision  can  be 
supplemented  by  a  second  one  at  right  angles  to  the  first,  begin- 
ning at  the  first  incision  on  a  level  with  the  external  auditory  canal 
and  extending  backward  an  inch. 

The  soft  tissues  being  severed  down  to  the  bone,  the  peri- 
osteum is  elevated  and  the  wound  retracted,  exposing  the  mastoid. 
The  antrum  is  located  by  attention  to  the  landmarks.  It  is  sit- 
uated just  behind  and  above  the  external  opening  of  the  meatus. 
The  meatus  is  marked  by  the  supermeatal  spine  or  the  spine  of 
Henle,  which  is  a  small  triangular  ridge  or  point  of  bone  project- 
ing forward  at  the  level  of  the  meatus.  Just  behind  this  spine  will 
be  found  an  area  of  bone  perforated  with  numerous  small  blood- 
vessels, which  ooze  more  than  any  other  part  on  the  surface  of 
the  exposed  bone.  The  perforator  or  chisel,  plied  at  this  point  to 
a  depth  of  a  half  inch  or  perhaps  less,  opens  into  the  mastoid 
antrum.  The  conical  layer  of  bone  from  this  opening  downward 
toward  the  tip  of  the  mastoid  and  all  about  should  be  removed  to 
a  sufficient  extent  to  expose  the  cells  in  the  tip  in  every  case,  and 
as  deeply  and  widely  as  necessary  to  see  and  remove  all  diseased 
bone.  For  this  work  of  exploring  and  clearing  out  cancellous  bone, 
no  instrument  is  so  useful  as  the  spoon-bowl  bone  curettes  in  dif- 
ferent sizes  and  shapes.  The  rongeur  is  best  for  the  margins  or 
the  cortex,  and  the  chisels  or  gouges  for  other  dense  bone.  It  may 
or  may  not  be  necessary  to  remove  the  cells  or  cancellous  bone 
from  the  root  of  the  zygoma,  to  remove  a  portion  of  the  inner  cortex 
or  expose  the  lateral  sinus.    Every  particle  of  diseased  bone  should 


386  SURGICAL   DISEASES    OF    CHILDREN 

be  cut  and  scooped  away,  and  the  cavity  mopped  repeatedly  until 
it  is  perfectly  clean. 

Drainage  is  generally  employed  in  the  dressing.  Healing  by 
organization  of  blood-clot  would  take  place  in  a  certain  percentage 
of  cases  if  the  wound  were  entirely  closed.  But  in  the  majority  of 
suppurative  cases  it  is  better  and  safer  to  introduce  a  small  wick 
drain  of  gauze  in  soft  rubber  tubing  to  the  bottom  of  the  bony 
wound  and  projecting  from  the  lower  angle  of  the  incision.  The 
remainder  of  the  wound  is  closed  by  suture.  A  small  wick  drain 
should  also  be  used  in  the  external  auditory  canal.  A  protective 
and  absorbent  dressing  of  gauze,  followed  by  cotton  and  a  ban- 
dage, is  applied  outside. 

If  all  goes  well  the  first  dressing  is  made  in  forty-eight  or 
seventy-two  hours  after  the  operation.  The  wick  drain  in  the  bony 
wound  is  removed  and  the  cavity  mopped  dry  and  clean  with  cotton 
on  an  applicator.  The  same  is  done  with  the  drain  in  the  external 
canal  and  the  outside  dressings  renewed.  A  similar  dressing  fol- 
lows daily  until  discharge  has  ceased,  when  the  drain  is  withdrawn 
and  the  wound  allowed  to  heal  from  the  bottom  by  granulation. 

If  there  is  no  further  complication,  such  as  sinus  thrombosis, 
labyrinthine  inflammation,  etc.,  the  wound  should  be  soundly  healed 
in  three  to  five  or  six  weeks. 

INFECTIVE  THROMBOSIS  OF  THE  LATERAL  SINUS 

Inflammation  may  extend  from  the  mastoid  or  from  the 
labyrinth  and  involve  the  wall  of  the  lateral  sinus.  In  the  great 
majority  of  the  cases  it  has  extended  from  the  mastoid.  If  the 
inflammatory  process  penetrates  the  wall  of  the  sinus  sufficiently 
to  affect  the  intima,  the  latter  loses  its  power  of  inhibiting  coag- 
ulation of  the  blood.  The  platelets  adhere  to  the  vessel  wall  at  this 
point,  and  soon  a  fibrinous  mass,  in  which  are  .entangled  corpus- 
cular elements  of  the  blood,  forms  upon  the  side  of  the  vessel 
and  still  further  impedes  the  naturally  slow  current  of  the  sinus. 
If  this  thrombotic  mass  does  not  completely  occlude  the  vessel  it 
is  called  a  lateral  or  incomplete  thrombosis.  But  the  impeded 
blood  current  eddies  in  passing  it  and  continues  to  deposit  coagula- 
ble  elements  until  the  lumen  of  the  channel  is  entirely  occluded. 
The  thrombus  quickly  becomes  infected,  and  there  is  great  danger, 
not  merely  of  embolism  from  detachment  of  a  portion  of  the  clot, 
but  of  the  absorption  of  toxins  by  the  blood  and  the  distribution 
of  the  infecting  agents  themselves  by  the  blood  stream.  The  result 
is  septicemia  or  pyemia.  Infective  emboli  may  lodge  and  set  up 
metastatic  inflammation  and  abscess  in  the  lungs,  the  liver,  the  kid- 
neys, or  the  brain.  The  formation  of  a  clot  is  nature's  effort  to 
erect  a  barrier  against  the  advancing  infection,  and  the  thrombus 


DEFORMITIES    AND    DISEASES   OF   THE   EAR  387 

temporarily  acts  as  such,  but  it  is  rare  to  have  organization  of  clot 
sufficiently  rapid  to  afford  any  effective  protection,  for  the  clot 
itself  usually  soon  undergoes  suppuration  and  disintegration,  with 
disastrous  general  results  before  mentioned. 

Symptoms,  Diagnosis  and  Prognosis. — Almost  invariably  there 
is  a  history  of  otitis  media,  and  frequently  the  progress  of  the  dis- 
ease can  be  traced  in  the  form  of  a  mastoiditis.  The  pathologic 
studies  of  Macewen  and  the  clinical  descriptions  of  Whiting  have 
not  been  excelled,  and  are  generally  accepted  as  both  truthful  and 
graphic.  Whiting  describes  the  course  of  sigmoid  sinus  thrombosis 
in  three  stages,  "  characterized  by  local  and  systemic  manifesta- 
tions. First  stage :  The  presence  of  a  thrombus,  parietal  or  com- 
plete, not  having  undergone  disintegration,  and  accompanied  by 
slight  or  moderate  pyrexia,  rigors  usually  being  insignificant  or 
absent.  Second  stage :  The  presence  of  a  thrombus,  parietal  or 
complete,  which  has  undergone  disintegration  with  resulting  sys- 
temic absorption,  characterized  by  frequent  rigors,  and  pronounced 
septico-pyemic  fluctuation  of  temperature.  Third  stage :  The  pres- 
ence of  a  thrombus,  parietal  or  complete,  which  has  undergone  dis- 
integration with  systemic  absorption,  accompanied  by  rigors,  rapid 
and  great  fluctuations  of  temperature,  and  central  or  peripheral 
embolic  metastasis,  terminating  usually  in  a  septic  pneumonia,  en- 
teritis, or  meningitis." 

Going  more  into  detail,  the  symptoms,  diagnosis,  and  prog- 
nosis, corresponding  to  the  stages  in  the  pathologic  process  as  de- 
scribed by  Macewen,  may  be  given  as  follows :  First  stage,  in 
which  the  thrombus  has  formed  either  partially  or  completely,  but 
disintegration  has  not  taken  place. 

The  symptoms  are  slight  or  moderate  fever ;  rigors ;  headache, 
limited  to  the  affected  side  and  either  slight  or  severe ;  slight  ten- 
derness over  the  region  of  the  emissary  vein ;  slight  edema  and 
tenderness  in  the  posterior  triangle  of  the  neck,  below  the  tip  of 
the  mastoid  process;  leucocytosis  with  increased  polymorpho- 
nuclears. / 

The  diagnosis  is  not  easily  made  in  the  first  stage  without  a 
mastoid  operation ;  but  the  occurrence  of  rigors  in  a  patient  with 
mastoiditis  should  lead  to  a  very  close  examination,  and  if  tender- 
ness be  found  in  the  upper  part  of  the  posterior  triangle  and  over 
the  mastoid  emissary  vein  with  edema  in  this  region,  and  especially 
if  there  is  leucocytosis  with  a  relatively  large  polymorphonuclear 
count,  a  mastoid  operation  with  exposure  and  examination  of  the 
sinus  is  justified.  The  prognosis,  if  diagnosis  and  operation  are 
made  at  this  time,  is  much  more  favorable  than  at  anv  later  period, 
nearly  all  cases  ending  in  recovery. 

In  the  second   stage  of  thrombosis,   whether   it  be  partial   or 


388  SURGICAL  DISEASES   OF  CHILDREN 

complete,  disintegration  of  the  clot  is  in  progress.  Fever  is  con- 
tinuous, but  rises  and  falls  irregularly.  Rigors  are  frequent.  Uni- 
lateral headache  is  marked.  Tenderness  over  the  mastoid  emissary 
vein;  tenderness  and  edema  in  the  posterior  triangle  of  the  neck 
beneath  the  tip  of  the  mastoid.  There  is  increase  in  the  number  of 
leucocytes  and  polymorphonuclears.  With  these  symptoms,  imme- 
diate operation  is  imperative.  The  most  favorable  time  for  opera- 
tion has  passed  by,  but  the  prognosis  only  darkens  with  delay. 
With  the  diagnosis  and  operation  made  in  the  second  stage,  the  rec- 
ords show  50  .per  cent,  of  recoveries. 

In  the  third  stage  of  thrombosis,  with  disintegration  of  the 
thrombus,  there  are  excessive  systemic  toxemia  and  metastases.  A 
chill  or  rigor  is  followed  by  extreme  fluctuation  of  temperature, 
which  may  drop  to  subnormal  and  then  rise  to  104  degrees  or  106 
degrees  F.  The  headache  becomes  almost  unbearable.  The  tender- 
ness over  the  region  of  the  mastoid  emissary  vein  and  the  posterior 
triangle  is  more  marked  and  may  extend  to  the  region  over  the  in- 
ternal jugular  vein.  There  may  be  symptoms  of  metastatic  pneu- 
monia, enteritis,  hepatitis  or  meningitis.  Unless  the  system  be  over- 
powered against  resistance  the  blood  examination  shows  a  rising 
number  of  leucocytes  and  polymorphonuclears.  The  final  symptom 
as  a  fatal  end  approaches  is  coma.  Very  few  cases  recover  once 
they  have  reached  the  third  stage,  whether  they  are  not  operated  or 
are  operated.  Yet  the  chance  of  an  operation  should  be  afforded 
them. 

The  diagnosis,  as  made  by  the  condition  of  the  sinus  upon 
operation,  will  be  included  in  the  description  of  the  operation. 

Surgical  Treatment  of  Thrombosis  of  Lateral  Sinus. — The 
mastoid  operation,  as  previously  described,  is  first  performed.  If 
the  primary  otitis  and  mastoiditis  are  acute,  it  is  probable  that  a 
simple  mastoid  operation  as  the  preliminary  step  to  exposing  the 
lateral  sinus  will  be  sufficient.  The  labyrinth  is  more  likely  to  be 
involved  in  a  chronic  case,  and  may  possibly  require  exenteration. 
The  sinus  is  then  exposed  by  removing  the  cortex  of  the  mastoid 
which  covers  it.  This  may  be  found  dense  or  necrotic.  Extra- 
dural abscess  of  the  sinus  may  perhaps  be  discovered  and  evacuated. 
The  sinus,  being  clearly  exposed  to  view,  is  carefully  examined. 
If  the  vein  is  normal  it  shows  a  dark  blue  color  and  a  lustrous  sur- 
face. On  touching  with  the  finger,  it  is  easily  compressible  and 
feels  soft  and  resilient.  A  probe  or  dissector,  laid  across  the  ves- 
sel and  pressed  down,  causes  it  to  flatten  below  the  obstruction,  while 
it  remains  full  and  convex  above  it.  If  the  wall  of  the  vessel  is 
inflamed  it  has  lost  a  part  of  its  surface  luster  and  deep  blue  color. 
Touch  with  the  finger  may  find  the  wall  abnormally  resistant, 
but  whether  because  the  inflammatory  thickening  or  from  the  pres- 


DEFORMITIES   AND   DISEASES   OF   THE   EAR  389 

ence  of  thrombus  within,  it  may  be  impossible  to  determine  by 
external  examination.  It  then  becomes  necessary  to  open  the 
vessel.  It  was  formerly  advised  to  aspirate  it  with  a  hypodermic 
needle.  But  it  is  better  and  safer  to  open  it  with  a  carefully  ster- 
ilized narrow-bladed  knife.  The  incision  is  made  lengthwise  of 
the  vessel.  If  the  blood  flows  freely  there  is  certainly  no  thrombotic 
occlusion.  But  if  the  blood  fails  to  flow  the  incision  should  be 
enlarged  upward  nearly  but  not  quite  to  the  limit  of  the  bony  open- 
ing. With  a  small  blunt  spoon  curette  the  contents  of  the  sinus 
are  then  examined.  The  clot  below  the  opening  is  scooped  out  until 
the  blood  flows  freely.  Then  the  vein  below  the  opening  is  com- 
pressed by  the  finger  or  a  sponge  of  iodoform  gauze,  while  the 
thrombus  is  removed  from  above  and  the  vessel  flushed  out  by 
bleeding.  The  bony  canal  both  above  and  below  the  opening  is 
then  plugged  by  packing  with  a  strip  of  iodoform  gauze,  thus  com- 
pressing and  occluding  the  vessel  at  both  sides  of  its  opening. 
The  whole  bony  opening  is  then  packed  with  idoform  or  cyanide 
gauze  and  a  dressing  applied  as  described  after  the  mastoid  opera- 
tion. If  all  goes  well  the  first  change  of  dressing  is  made  forty- 
eight  hours  after  the  operation.  But  if  chills  occur  or  the  tem- 
perature rises  the  wound  must  be  opened  and  investigated.  A 
perisinous  abscess  may  be  found ;  or  a  portion  of  the  thrombus  may 
have  been  left  within  the  sinus  and  have  to  be  removed.  Or  the 
jugular  bulb  and  vein  may  be  thrombotic  and  infected  and  require 
resection. 

INTRACRANIAL    EXTENSION     OF    EAR    DISEASE    TO    THE 
MENINGES  OR  THE  BRAIN 

Septic  inflammation  may  extend  from  the  ear  to  the  membranes 
of  the  brain  or  to  the  brain  itself  through  the  petrosquamosal  suture 
in  the  roof  of  the  tympanic  cavity,  or  by  first  invading  the  mastoid. 
From  the  mastoid,  disease  may  extend  through  the  very  thin  roof 
of  the  antrum  of  the  mastoid,  or  by  way  of  the  covering  of  the 
lateral  sinus,  or  at  the  tip  of  the  mastoid.  In  infants  and  children 
inflammation  is  more  apt  to  extend  through  the  roof  of  the  tympanic 
cavity  than  in  older  patients,  and  this  can  occur  in  acute  cases ;  but 
in  patients  at  any  age  extension  to  meninges  or  brain  is  more  likely 
to  occur  as  a  sequence  of  subacute  or  of  chronic  than  of  acute  ear 
disease;  and  in  the  majority  the  disease  progresses  by  way  of  the 
mastoid. 

The  condition  may  be  one  in  which  a  purulent  collection  in 
tympanic  or  antral  cavities  or  mastoid  cells  is  forced  by  its  own 
tension  through  disintegrating  cortical  bone,  and  may  constitute 
essentially  a  local  abscess  between  the  cranium  and  the  dura — an 
extra-dural  abscess.    Or  the  dura  may  be  penetrated  by  the  infective 


390  SURGICAL   DISEASES    OF   CHILDREN 

organisms,  resulting  in  pachymeningitis.  If  inflammatory  ad- 
hesions seal  the  dura  to  the  bone  in  the  circle  surrounding  the  area 
of  inflammation  the  condition  is  for  the  time  a  limited  external 
pachymeningitis.  But  if  the  inflammation  travels  too  fast  for  the 
erection  of  nature's  barriers,  the  pachymeningitis  becomes  more 
widespread  or  diffuse.  In  other  cases  the  piamater  is  infected,  and 
to  its  delicate  and  vascular  structure  serious  and  often  widespread 
damage  usually  results.  The  disease  may  be  limited  to  the  area 
near  the  point  of  infection,  but  it  is  prone  to  extend  and  may  cover 
the  entire  surface  of  the  brain.  In  leptomeningitis  also  the  cerebro- 
spinal fluid  becomes  infected ;  and  if  the  patient  does  not  succumb 
to  general  toxemia,  abscess  may  follow  in  any  portion  of  the  nervous 
system  covered  by  the  pia.  In  leptomeningitis  the  brain  itself  is 
not  so  frequently  involved  as  one  might  expect,  though  occasionally 
superficial  infiltration,  edema  and  softening  may  occur. 

Again,  without  any  visible  involvement  of  intervening  bone  or 
membranes,  infective  organisms  from  the  ear  find  their  way  into  the 
substance  of  the  brain  adjacent,  usually  the  white  matter  in  the 
temporo-sphenoidal  lobe,  or  less  frequently  the  cerebellar  lobe,  and 
there  produce  inflammation  and  resultant  abscess.  It  is  a  possibility 
for  any  of  these  inflammations  to  be  limited  in  extent,  although  a 
leptomeningitis  is  little  apt  to  do  so,  and  for  an  abscess  of  mem- 
branes or  of  brain  to  become  encapsulated  and  to  remain  for  a  time 
quiescent,  or  to  find  its  way  to  the  surface  and  to  discharge  itself 
through  the  ear ;  but  such  results  are  extremely  unusual,  and  cannot 
be  hoped  for  nor  waited  for  without  surgical  intervention,  A  fatal 
termination  is  far  more  probable. 

Symptoms  and  Diagnosis. — The  great  majority  of  cases  of  in- 
tracranial extension  of  ear  disease  present  the  symptoms  of  otitis 
media  purulenta,  and  some  of  them  add  also  the  symptoms  of 
mastoiditis,  both  of  which  have  already  been  described.  Up  to 
this  point  all  cases  are  much  alike,  excepting  those  that  do  not 
extend  by  continuity  but  by  lymph  or  blood  channels  leaving  in- 
tervening tissues  unaffected.  But  the  diagnosis  of  intracranial 
invasion  and  the  differentiation  between  its  various  forms  is  often 
a  matter  of  the  greatest  difficulty.  Certain  symptoms  and  symptom 
groups  characterize  the  different  intracranial  inflammations  and  may 
be  recognized  when  they  occur  alone  and  in  typical  form.  But 
atypical  cases  occur,  and  again  cases  partaking  of  the  character  of 
more  than  one  clinical  form  of  disease,  which  it  may  be  impossible 
to  differentiate  before  operation.  Lateral  sinus  thrombosis,  besides 
the  symptoms  of  mastoiditis,  usually  presents  a  chill  or  a  series  of 
chills,  followed  by  a  high  and  fluctuating  temperature.  The  chill  or 
chills  might  also  indicate  leptomeningitis  or  brain  abscess ;  but  with 
the  leptomeningitis  the  temperature  is  more  apt  to  be  persistently 


DEFORMITIES    AND    DISEASES    OF    THE    EAR  391 

high,  even  if  variable,  and  to  be  accompanied  by  symptoms  of  irri- 
tation, such  as  nausea  or  vomiting,  vertigo,  dehrium,  rigidity  of 
the  muscles  of  the  neck  with  retraction  of  the  head,  Kernig's  sign, 
irregular  pupillary  reactions,  hypersesthesia,  Cheyne-Stokes  respira- 
tion, paralysis,  stupor,  coma,  and  death. 

Headache  is  common  to  all  the  intracranial  inflammations. 
It  is  probably  more  severe  in  pachymeningitis  than  in  leptomenin- 
gitis, is  more  apt  to  be  localized  in  abscess  of  brain  and  to  be 
occipital  in  location  if  the  abscess  is  in  the  cerebellum.  Percussion 
over  the  site  of  an  abscess  may  increase  the  pain.  Optic  neuritis 
may  accompany  either  leptomeningitis  or  brain  abscess.  In  cere- 
bral abscess,  besides  the  symptoms  of  otitis  or  mastoiditis  which 
may  precede  it,  and  besides  the  symptoms  of  cerebral  irritation  and 
the  chill  or  chills  which  may  mark  its  onset,  there  is  apt  to  be  a  per- 
sistent fever  of  low  grade — much  lower  degree  than  usually  pertains 
to  meningitis,  or  even  a  subnormal  temperature,  and  a  markedly 
slow  pulse. 

There  may  be  localizing  symptoms  if  any  of  the  definite  motor 
centers  or  the  speech  center  are  involved.  (See  Section  on 
Cranio-Cerebral  Topography.) 

The  rupture  of  a  brain  abscess  and  escape  of  its  contents  into 
a  ventricle  or  into  a  subdural  space  may  set  up  a  leptom;eningitis 
with  its  characteristic  symptoms. 

With  cerebellar  abscess,  in  addition  to  the  headache,  which 
may  be  localized  in  the  occiput,  and  the  vertigo  and  vomiting,  which 
are  apt  to  be  severe,  a  typical  case  presents  symptoms  of  muscular 
incoordination.  But  in  abscess  as  in  brain  tumor,  the  localizing 
symptoms  are  often  so  indefinite  as  to  make  differential  diagnosis 
between  cerebral  and  cerebellar  disease  difficult  or  impossible. 

Prognosis. — Cure  of  cerebral  abscess  without  surgical  inter- 
vention, at  least  temporary  cure,  is  a  possibility ;  but  as  a  rule  a  fatal 
result  is  to  be  expected  if  operation  is  not  done.  On  the  other 
hand,  skillful  interference  may  save  an  apparently  desperate  case. 
Extradural  abscess  when  emptied  and  cleaned  out  affords  a  favorable 
prognosis.  Abscess  in  the  brain  gives  a  much  graver  prognosis. 
It  is  much  harder  to  locate,  and  its  situation  may  be  inaccessible. 
Then  its  evacuation  and  the  drainage  of  the  cavity  may  be  difficult 
to  manage.  However,  if  the  abscess  is  in  the  temporal  lobe,  there  is 
a  fair  prospect  of  success.  With  abscess  in  the  cerebellum  there  is 
apt  to  be  coincident  septic  thrombosis  of  the  lateral  sinus,  compli- 
cating the  case  and  rendering  it  extremely  grave. 

Leptomeningitis  affords  but  little  hope  of  recovery.  Still,  an 
effort  should  be  made  by  exposure  of  the  meninges,  irrigation  and 
drainage  through  the  cranial  wound  and  through  lumbar  punctures, 
as  a  number  of  successful  cases  have  been  reported. 


392  SURGICAL  DISEASES    OF   CHILDREN 

Treatment. — In  the  treatment  of  extfadural  abscess  following 
a  mastoid  operation,  the  bone  covering  the  abscess  cavity  should  be 
removed  with  chisel,  gouge,  curette  or  rongeur.  Care  should  be 
taken  in  those  cases  in  which  the  abscess  cavity  is  limited  by  adhe- 
sion of  the  dura  to  the  cranium  not  to  remove  bone  beyond  the  ad- 
hesion nor  to  break  through  the  walls  of  the  cavity.  If  these  walls 
are  covered  with  granulations  they  should  be  cleaned  by  scraping 
and  mopping  with  gauze  sponges.  The  abscess  cavity  is  drained 
with  iodoform  gauze  and  the  mastoid  wound  drained  and  packed 
as  usual. 

For  the  treatment  of  intradural  and  of  brain  abscess  it  is 
necessary  by  close  study  of  the  localizing  symptoms,  together  with 
the  history  and  condition  of  the  primary  ear  disease,  to  form  a 
reasonable  conception  of  the  situation  of  the  abscess.  If  the  disease 
has  extended  by  continuity  it  is  usually  best  to  follow  it  in  the 
operation  by  the  same  route.  As  before  stated,  if  in  the  cerebrum 
the  abscess  is  most  likely  to  be  found  just  over  the  roof  of  the 
tympanum  or  of  the  antrum  of  the  mastoid,  and  is  best  exposed  by 
first  opening  and  clearing  out  the  mastoid  and  these  cavities  and 
then  removing  the  cortex.  The  condition  of  the  dura  as  to  its  color, 
its  resistance  to  touch  and  the  degree  of  tension  behind  it  will  prob- 
ably make  it  evident  whether  it  should  be  incised.  If  fluctuation  be 
felt  beneath  the  dura,  or  it  bulge  abnormally  into  the  wound,  it 
should  be  carefully  opened  with  a  small  bistoury  and  this  incision 
enlarged  with  scissors.  The  abscess  may  be  found  immediately  be- 
neath, or  the  edematous  or  softened  condition  of  the  brain  may  give 
evidence  that  it  is  close  at  hand.  If  not,  the  brain  must  be  explored 
in  the  direction  judged  most  promising  by  the  localizing  symptoms. 
For  exploration  a  slender  expanding  forceps  or  a  grooved  director  is 
better  than  an  aspirating  needle  or  fine  trocar.  When  found  the 
abscess  should  be  evacuated  through  an  opening  large  enough  to 
introduce  a  drainage  tube,  and  to  permit  of  lavage  with  sterile 
normal  salt  solution  at  subsequent  dressings.  If  a  leptomeningitis 
be  found  the  infected  cavity  should  be  irrigated  with  sterile  normal 
salt  solution,  and  if  the  meningitis  has  become  general  the  entire 
cerebro-spinal  serous  cavity  should,  by  means  of  lumbar  punctures 
and  the  cranial  opening,  be  drained  and  irrigated.  (See  also  Sec- 
tion on  Operations  on  the  Cranium.) 


CHAPTER  XV 

THE  PARALYSES  OF  INFANCY  AND  CHILDHOOD  AND 
OPERATIONS  UPON  NERVES 

The  Paralyses  of  Infancy  and  Childhood — Birth  Palsies 
Non-central  in  Origin — Acute  Anterior  Polioaiyelitis — 
Cerebral  Paralyses — Operations  upon  Nerves. 

A  variety  of  paralyses  occur  in  infants  and  children,  though 
in  widely  varying  degrees  of  frequency.  See  Appendix  (57). 
I  will  devote  space  here  to  some  of  the  other  paralyses  which  occur 
most  frequently  and  which  have  the  greatest  surgical  interest. 

BIRTH  PALSIES  NON-CENTRAL. 

Facial  paralyses. — Pressure  of  maternal  parts  or  instruments 
upon  the  facial  nerve,  near  its  exit  from  the  stylomastoid  foramen 
or  over  the.  ramus  of  the  jaw  or  upon  some  of  its  terminal  branches 
may  cause  paralysis  of  one  side  of  the  face  or  some  part  of  it. 
(Bell's  palsy.)     The  great  majority  of  these  cases  recover. 

Paralysis  of  the  upper  extremity. — This  is  more  likely  to  occur 
in  artificial  but  may  occur  during  spontaneous  delivery.  The  in- 
jury to  nerves  may  be  caused  by  pressure  of  the  blade  of  the  forceps 
on  the  neck  or  pressure  at  the  root  of  the  neck  by  the  fingers  of  the 
accoucheur  in  efforts  at  delivery  in  head-last  cases ;  or  by  traction 
with  fingers  hooked  into  axilla  or  by  traction  upon  the  arm.  Other 
damage  may  be  inflicted  at  the  same  time,  such  as  separation  of  the 
upper  epiphysis  of  the  humerus,  fracture  of  clavicle  or  rupture  of 
fibres  of  sternomastoid.  The  point  usually  injured  is  the  fifth  and 
sixth  cervical  nerves.  This  may  lead  to  paralysis  of  the  deltoid, 
the  infra-spinatus,  biceps,  brachialis  anticus,  supinator  longus  and 
infra-spinatus,  called  Erb's  paralysis  or  "upper-arm  type."  Only  a 
part  of  these  muscles  may  be  paralyzed,  not  all  to  the  same  degree, 
varying  greatly  in  different  cases,  or  sometimes  the  serratus  be- 
sides. Injury  above  the  clavicle  will  not  only  involve  the  circum- 
flex nerve,  but  also  the  musculo-spiral ;  and  if  the  location  of  the 
injury  is  in  the   foramina,  movements  of  the  diaphragm  will  be 

1  It  is  probable  that  myotonia  congenita  also  should  be  classed  with  the 
muscular  dystrophies.  See  Batten :  "  Myopathies  or  muscular  dystrophies," 
Quar.  Jour.  Med.,  Oxford,  April,  1910. 

393 


394  SURGICAL   DISEASES    OF   CHILDREN 

affected  through  impairment  of  at  least  a  part  of  the  origin  of  the 
phrenic. 

The  paralysis  may  be  noticed  at  once,  or  not  observed  for  days, 
w.eeks  or  months.  The  attitude  of  the  arm  is  characteristic.  It 
hangs  helpless,  with  the  forearm  pronated,  and  the  arm  rotated  in- 
ward, so  that  the  palm  is  turned  outward  and  backward.  The  tri- 
ceps is  not  affected.  If  the  arm  is  flexed  it  can  be  voluntarily 
extended.  But  voluntary  flexion,  supination  or  abduction  are  not 
performed.  After  several  w.eeks,  atrophy  of  the  paralyzed  muscles 
begins.  But  in  the  infant  the  muscles  are  so  small  and  the  sub- 
cutaneous fat  so  abundant  that  the  atrophy  can  scarcely  be  detected 
in  the  first  year. 

Diagnosis. — The  diagnosis  presents  no  difflculty  if  the  case  is 
typical  and  is  seen  early  before  there  can  be  any  question  of  polio- 
myelitis anterior  acuta.  When  other  injury,  such  as  fractured  clav- 
icle, or  humerus,  or  neck  of  the  scapula,  is  present,  the  inability  to 
use  the  arm  may  be  attributed  to  that,  and  the  nerve  condition  not 
discovered  until  later.  An  old  traumatic  deformity  might  mask  the 
paralysis,  but  an  electrical  test  would  discover  it.  Syphilitic  epiphy- 
sitis, or  the  pseudo-paralysis  of  infants,  might  superficially  resem- 
ble Erb's ;  but  in  the  former  there  is  tenderness  and  an  annular 
swelling  at  the  epiphysis,  no  real  paralysis,  probably  other  epiphyses 
affected  and  other  evidences  of  sphyilis.  The  peculiar  group  of 
muscles  paralyzed  is  characteristic.  If  the  surgeon  has  ever  seen  a 
case  he  is  not  apt  to  overlook  one. 

Prognosis. — The  prognosis  can  only  be  made  by  judging  the 
extent  of  the  injury  and  its  progress  toward  spontaneous  recovery, 
together  with  the  location  of  the  lesion  and  its  accessibility  to  sur- 
gical repair.  Moderate  cases  recover  spontaneously  in  a  few  months. 
But  if  three  months  have  passed  without  improvement  there  is 
little  hope  of  recovery  by  natural  processes.  Kennedy  places  the 
waiting  time  at  two  months.  If  the  muscles  then  show  response  to 
the  faradic  current,  recovery  will  probably  take  place  without  sur- 
gical intervention.  If  they  do  not  respond  to  faradism,  but  respond 
to  galvanism,  an  operation,  if  practicable,  is  indicated  with  some 
prospect  of  improvement  or  recovery. 

Treatment. — During  the  first  few  weeks  no  attempt  at  treat- 
ment is  of  any  use.  After  the  first  month,  if  the  muscles  respond 
to  faradic  electricity,  it  should  be  used  regularly  and  persistently, 
but  not  too  much  expected  from  it.  If  the  muscles  do  not  respond 
to  faradism,  galvanism  should  be  used.  Massage  also  is  advisable 
in  all  cases.    The  prospects  of  recovery  are  poor  without  operation. 

The  operative  treatment  for  Erb's  paralysis  was  pioneered  by 
Robert  Kennedy,  whose  operation  is  thus  described :  ^     The  patient 

1  Brit.  Med.  Jour.,  Feb.  7,  1903. 


THE    PARALYSES    OE   INEANCY    AND    CHILDHOOD        395 

is  placed  upon  his  back  with  a  pad  under  the  shoulders,  so  that  the 
head  is  extended,  and  the  head  and  face  turned  toward  the  opposite 
side.  A  long  incision  is  made,  beginning  at  the  junction  of  the 
middle  and  lower  thirds  and  at  the  outer  margin  of  the  sterno- 
mastoid  and  carried  to  the  junction  of  the  middle  and  outer  thirds 
of  the  clavicle.  The  deep  fascia  is  divided  between  the  sterno- 
mastoid  and  the  trapezius ;  and  the  omohyoid  exposed  below  the 
lower  edge  of  the  wound.  Above  the  omohyoid  the  scalenus  anticus 
is  exposed  and  under  it  the  nerve  trunks  emerge.  The  two  upper 
nerve  trunks  are  traced  outward  to  their  junction,  and  they  and 
their  branches  are  freed  from  adhesions. 

The  nerve  will  probably  be  found  in  a  cicatricial  condition. 
If  the  entire  nerve  seems  to  be  scar-tissue  the  fifth  and  sixth  should 
be  divided  above  the  damaged  area.  The  cut  surface  should  show 
a  healthy  appearance ;  if  it  does  not,  more  and  more  of  the  nerve 
must  be  sliced  off  until  healthy  tissue  is  reached.  The  diseased  area 
is  then  pulled  inward  and  the  three  peripheral  divisions  of  the  nerve, 
namely,  the  supra-scapular,  the  branch  to  the  outer  and  that  to  the 
inner  cord  of  the  plexus,  are  put  on  the  stretch.  These  three 
branches  are  then  divided,  through  sound  tissue.  The  three  periph- 
eral stumps  are  then  sutured  to  the  two  proximal  stumps  with 
fine  chromicized  catgut.  Before  approximating  the  divided  nerve 
ends  and  tying  the  sutures,  the  shoulder  should  be  elevated  and 
the  head  bent  to  the  side  toward  the  field  of  operation,  to  permit  the 
approximation  of  the  ends  and  relieve  tension  on  the  sutures. 

The  external  wound  is  then  closed ;  and  after  the  antiseptic 
dressings  are  applied  a  plaster  bandage  is  put  on,  holding  the 
shoulder  in  an  elevated  position  and  the  head  inclined  toward  it, 
and  immovably  fixed.    The  fixed  dressings  are  used  two  weeks.  (28) 

ACUTE    ANTERIOR    POLIOMYELITIS    (INFANTILE    SPINAL 

PARALYSIS;   ACUTE   ATROPHIC    SPINAL    PARALYSIS; 

MYELITIS    OF    THE    ANTERIOR    HORNS) 

This  is  the  most  common  form  of  paralysis  in  infancy  and 
childhood.     The  real  cause  of  the  disease  is  unknown.  (29) 

Judged  by  the  symptoms  the  disease  attacks  the  entire  central 
nervous  system  and  also  its  meninges.  Not  only  the  gray  matter 
of  the  anterior  horns,  of  the  cortex,  bulb  and  brain  stem  are 
afifected,  but  also  the  white  matter.  But  with  all,  excepting  the 
gray  matter  of  the  anterior  columns  of  the  cord,  the  afifection  goes 
no  farther  than  an  irritation.  So  that  judged  by  lesions  that  can 
be  found  the  disease  is  an  acute  myelitis  with  its  focus  in  one  of  the 
anterior  columns  of  the  spinal  cord,  though  it  may  extend  iato  the 
adjacent  antero-lateral  column.  It  is  limited  also  in  vertical  extent 
to  a  fraction  of  an  inch  or  an  inch.     Tliere  may  be  more  than  one 


396  SURGICAL   DISEASES    OF   CHILDREN 

focus  of  disease,  and  both  sides  of  the  cord  may  be  attacked,  usually 
not  with  the  same  degree  of  severity.  The  cause  seems  to  act 
through  the  blood  vessels,  producing  dilatation  and  sometimes  throm- 
bosis, and  resulting  in  granular  degeneration  of  the  large  motor 
cells. 

The  later  changes  are  cicatricial  or  sclerotic.  The  destruction 
of  nerve  elements,  both  ganglionic  cells  and  white  matter,  and  the 
contraction  of  connective  tissue,  produce  a  narrowing  or  shrinking 
in  the  affected  area  of  the  cord  that  is  readily  apparent.  The  de- 
generation extends  into  the  nerve  roots,  and  into  the  nerves. 
Trophic  changes  take  place  also  in  the  muscles  of  corresponding 
nervous  area;  they  undergo  atrophy  with  fatty  and  fibrous  degen- 
eration. Trophic  changes  also  affect  the  bones  and  other  structures 
of  the  paralyzed  part  which  fail  to  grow  at  the  normal  rate  in  length 
and  thickness. 

Symptoms. — As  a  rule  there  is  sudden  fever,  lOO  to  104;  with 
vomiting,  pains  in  the  extremities  and  nervous  excitement,  crying 
or  insomnia.  The  paralysis  may  appear  on  the  second  day  or  be 
discovered  after  a  few  days  as  the  illness  subsides.  In  some  cases 
the  symptoms  are  much  more  severe,  with  higher  fever,  104,  105 
or  even  more,  pains  in  back  and  extremities,  retraction  of  the  head, 
rigidity  of  the  neck,  convulsions,  starting  and  screaming,  coma, 
opisthotonos,  sometimes  death,  or  an  illness  prolonged  a  few  days 
or  a  week.  On  the  other  hand,  every  practitioner  has  seen  cases 
in  which  a  child  without  apparent  illness  was  found  one  morning 
to  be  paralyzed.  The  history  of  one  of  my  cases  reads :  "  His  par- 
ents say,  '  When  he  was  one  year  old  he  was  taken  sick  and  a 
doctor  gave  him  some  medicine  which  made  him  go  to  sleep,  and 
when  he  woke  up  he  was  paralyzed.'  "  Such  a  history  is  not  un- 
common. But  the  paralysis  is  not  due,  as  the  parents  allege,  to 
the  doctor's  medicine. 

The  extent  and  distribution  of  the  paralysis  vary  greatly 
within  certain  Hmits.  The  paralysis  may  appear  widespread  during 
the  illness  or  upon  its  cessation,  but  in  a  week  or  two  it  begins  to 
disappear,  excepting  in  one  limb  or  two  which  remain  permanently 
paralyzed.  But  even  in  the  primary  paralysis  the  respiratory  muscles 
are  seldom  seriously  affected  and  the  sphincters  usually  escape.  In 
a  study  of  500  cases  occurring  in  the  epidemics  of  1906  and  1907 
Collins  and  Romeiser  tabulate  the  distribution  of  the  paralyses  as 
follows:  Leg,  216,  both,  134;  arm,  36,  both,  5 ;  triplegia,  27;  quadri- 
plegia,  32;  homolateral,  20;  crossed,  13;  "other,"  136;  cranial,  35. 

Distribution  of  the  "  other  "  paralyses  was  as  follows  :  Abdomen 
and  diaphragm,  29 ;  lumbar  and  gluteal,  65  ;  back,  20 ;  chest,  9 ;  neck, 
29;  sphincters,  6. 

Distribution  of  the  cranial   (nuclear)   paralyses:  Rectus  colli, 


THE   PARALYSES    OF   INFANCY   AND   CHILDHOOD        397 

15;  facial,  9;  larynx  and  tongue  (aphonia  and  anarthria),  14;  pha- 
rynx, 3. 

The  relative  frequency  is  indicated  in  the  following  order:  I, 
leg;  2,  legs  only;  3,  arm;  4,  quadriplegia ;  5,  triplegia;  6,  hemi- 
plegia ;  7,  contralateral ;  8,  both  arms  only. 

The  residual  paralysis  usually  affects  only  certain  muscles  or 
muscle  groups,  and  not  the  entire  musculature  of  the  affected  mem- 
ber. The  most  common  form  is  paralysis  of  the  lower  extremity ; 
it  may  be  the  anterior  tibial  group,  or  the  peroneals,  or  these 
with  the  posterior  tibial  and  the  quadriceps.  The  extensors  are 
more  often  or  more  severely  affected  than  the  flexors.  The  ham- 
string muscles  and  the  glutei  are  apt  to  escape ;  but  sometimes 
the  paralysis  of  an  extremity,  for  instance  a  leg,  is  so  complete  that 
it  dangles,  a  mere  useless  appendage.  Paralysis  of  both  lower  ex- 
tremities may  occur,  partial  or  more  severe.  Paralysis  of  an  upper 
extremity  may  occur,  but  usually  in  association  with  paralysis  of 
one  or  both  lower  extremities ;  if  only  one,  it  is  upon  the  opposite 
side.  Of  the  muscles  of  the  upper  extremity  the  deltoid  is  fre- 
quently affected,  and  it  may  be  singly,  or  together  with  the  biceps, 
the  brachialis  anticus  and  the  supinator  longus.  This  is  the  so-called 
"  upper  arm  type."  In  the  "  lower  arm  type  "  the  extensors  or 
the  flexors  of  the  wrist  or  fingers  are  paralyzed.  In  the  forearm 
type  the  triceps  is  paralyzed.  Thus  it  is  seen  that  the  muscles  which 
are  associated  in  function,  rather  than  in  anatomical  relation,  are 
paralyzed  together.  Some  of  the  muscles  of  the  trunk  may  be 
paralyzed.  Those  of  the  face  are  seldom  affected  at  any  stage. 
Faradic  excitability  is  lost  or  lessened  in  the  primary  illness.  It 
may  be  entirely  gone  in  the  most  severely  affected  areas  at  the  end 
of  a  week,  and  the  reaction  of  degeneration  is  demonstrable.  After 
a  time,  as  the  muscles  themselves  atrophy,  galvanic  excitability 
lessens.  In  partially  paralyzed  muscles,  which  are  capable  of  im- 
provement by  electricity,  the  faradic  response  is  present  in  a  slight 
degree  although  feeble.  The  paralyzed  limb  is  cold  and  relaxed. 
The  cutaneous  sensibility  is  not  lost.    The  reflexes  are  absent. 

Deformities  result  from  the  paralysis,  the  contraction  of  unop- 
posed muscles,  and  trophic  changes.  Wryneck  may  occur  if  a 
sterno-mastoid  is  paralyzed.  Paralysis  of  the  deltoid  may  allow 
subluxation  of  the  head  of  the  humerus.  The  hip  may  become  dis- 
located upon  the  dorsum  ilii  in  old  cases  of  paralysis  of  the  muscles 
connecting  pelvis  and  femur.  Paralysis  of  the  erector  spinas  or 
shortening  of  one  lower  extremity  may  cause  spinal  curvature. 
The  thigh  may  become  flexed  and  contractured,  causing  lordosis 
on  attempting  to  straighten  the  limb.  Flexion  of  the  knee  with 
subluxation  of  the  head  of  the  tibia  may  occur,  or  hyperextension 
of  the  knee,  or  knock-knee.    Or  the  whole  limb  may  become  rotated 


398  SURGICAL   DISEASES    OF    CHILDREN 

outward  by  paralysis  of  the  adductors  and  extensors  of  the  thigh; 
or  the  leg  from  the  knee,  or  the  foot  from  the  ankle,  may  hang 
flail-like.  Various  forms  of  paralytic  talipes  occur — equino-varus, 
calcaneo-valgus,  equinus,  calcaneus,  and  cavus. 

Diagnosis. — The  symptoms  of  the  acute  stage  are  common  to  so 
many  diseases  that  usually  no  diagnosis  can  be  made  until  the  paraly- 
sis is  observed.    Then  there  should  be  no  difficulty.  (30) 

Cerebral  paralysis  may  begin  suddenly  and  with  convulsions. 
But  there  are  usually  more  cerebral  symptoms,  and  the  reflexes  are 
exaggerated.  The  paralysis  is  usually  hemiplegic,  and  the  face  also 
affected.  There  is  rigidity  with  the  paralysis  and  the  atrophy  is  not 
marked  nor  rapid.    There  is  no  reaction  of  degeneration. 

Acute  transverse  myelitis  is  rare  in  childhood.  It  affects  both 
legs  and  usually  involves  sensation  as  well  as  motion,  and  often  the 
sphincters;  it  has  exaggerated  knee-jerk  and  ankle-clonus;  no  reac- 
tion of  degeneration,  slight  atrophy,  but  a  proneness  to  bedsores. 

Spinal  paralysis,  due  to  hemorrhage  into  the  cord,  involves  sen- 
sation, motion  and  the  sphincters,  and  soon  shows  a  proneness  to 
form  bedsores. 

The  pseudo-paralysis  of  scurvy  has  been  mistaken  for  polio- 
myelitis ;  but  the  condition  is  very  different  if  one  has  the  typical 
symptoms  of  tenderness  over  the  epiphyses  and  the  long  bones,  espe- 
cially of  the  lower  extremities,  the  pain  on  motion,  the  spongy  gums 
and  ecchymoses.  However,  one  has  seen  scurvy  with  considerable 
pseudo-paralysis  and  without  either  spongy  gums  or  ecchymoses. 

Diphtheritic  paralysis  might  be  mistaken  for  infantile  paralysis. 
But  the  former  most  often  affects  the  throat  and  respiratory  mus- 
cles, which  are  less  often  aft'ected  in  infantile  paralysis.  And  one 
has  the  aid  of  the  history  of  a  preceding  diphtheria.  If  there  is 
still  doubt,  a  few  weeks'  time  will  tell  the  truth. 

There  is  some  resemblance  between  poliomyelitis  and  what 
Fothergill  called  "  the  muscular  listlessness  of  malnutrition."  But 
careful  examination  will  show  that  in  the  latter  there  is  no  real 
paralysis  and  that  the  weakness  is  general,  and  often  accompanied 
with  definite  signs  of  rickets.  Failing  in  these  points,  the  electrical 
reactions  should  be  tested. 

Congenital  dislocation  of  the  hip  has  been  mistaken  for  paraly- 
sis.   But  there  is  no  paralysis  nor  wasting. 

Hip-joint  disease,  too,  is  one  that  it  w^ould  not  be  necessary  to 
mention  in  this  connection,  but  that  mistakes  still  occur.  Although 
hip-joint  disease  has  lameness  and  wasting,  there  the  resemblance 
ends.  The  limb  is  not  cold  nor  flaccid.  There  is  usually  muscular 
contraction  about  the  joint  and  limitation  of  motion,  and  a  history 
of  a  chronic  inflammation  instead  of  an  acute  disease  which  passed 
bv  and  left  only  the  result. 


THE    PARALYSES    OF    INFANCY    AND    CHILDHOOD        399 

Prognosis. — There  is  said  to  be  very  little  danger  of  death  from 
this  disease.  I  have  sometimes  queried  whether  a  few  of  the  deaths 
charged  to  "  convulsions,"  "  teething,"  "  meningitis,"  "  acute  gas- 
tritis," and  so  on,  were  not  due  to  poliomyelitis  in  the  acute  stage. 
However,  the  prevailing  opinion  is  that  death  is  rare  from  this  dis- 
ease. As  to  permanency  of  the  paralysis — it  is  only  the  very  slight 
case  that  completely  recovers.  When  the  paralysis  is  demonstrated 
it  has  probably  reached  its  worst  as  far  as  motion  is  concerned. 
Wasting  will  follow.  Improvement  is  sure  to  come  to  some  extent. 
When  the  febrile  stage  is  passed  the  muscles  should  be  tested  with 
the  faradic  current.  Such  as  entirely  fail  to  respond  may  be  ex- 
pected to  waste.  If  faradic  reaction  improves,  improvement  in  mo- 
tion and  nutrition  may  be  expected.  If  no  response  is  shown  in  six 
months,  no  improvement  is  to  be  expected.  Improvement  usually 
begins  during  the  second  week  and  continues  for  perhaps  two 
months.  After  that  progress  is  slower  for  a  few  months.  The 
period  when  improvement  will  cease  depends  a  great  deal  upon  the 
treatment  employed.  Failure  of  growth  in  a  severely  affected  limb 
is  increasingly  noticed  as  time  goes  on.  The  other  deformities  can 
for  the  most  part  be  prevented  if  care  is  taken.  Almost  all  cases 
coming  to  the  surgeon  after  paralysis  and  deformity  are  established 
can  be  improved  in  some  way,  either  by  mechanical  or  operative 
means. 

Treatment — Drug  treatment  apparently  avails  little  in  this  dis- 
ease, and  the  subject  is  sufficiently  discussed  in  works  on  medical 
pediatrics.  Massage,  gymnastics  and  faradic  electricity  will  do 
much  to  prevent  wasting  of  the  muscles,  and  failure  in  growth ;  and 
to  maintain  them  in  condition  and  position  to  prevent  deformity, 
and  to  take  advantage  of  the  aid  that  can  be  rendered  by  mechanical 
and  operative  treatment.  (31) 

Mechanical  and  Operative  Treatment. — No  sooner  is  paralysis 
discovered  than  means  should  be  employed  to  prevent  the  deformity 
that  will  surely  occur  to  some  degree  if  the  case  is  neglected.  The 
point  is  to  keep  the  paralyzed  extremities  in  a  natural  position,  not 
allowing  unopposd  unparalyzed  muscles  by  their  constant  contrac- 
tion to  maintain  a  position  of  deformity  until  permanent  contracture 
on  the  one  side  and  overstretching  on  the  other  side  results.  More- 
over, maintaining  a  natural  position  gives  partially  paralyzed  muscles 
an  opportunity  to  act  so  far  as  they  are  able,  and  this  improves  their 
nutrition  and  their  innervation.  With  a  patient  in  bed,  very  slight 
mechanical  support  with  pillows  or  sandbags  or  light  splints  is  all 
that  is  necessary  to  hold  the  joint  half-way  between  flexion  and 
extension  or  between  pronation  and  supination,  or  between  outward 
and  inward  rotation.  As  soon  as  the  patient  is  able  to  be  up  or  to 
get  about,  some  apparatus  should  be  devised,  whether  of  leather,  of 


400 


SURGICAL  DISEASES    OF   CHILDREN 


gypsum  or  felt,  tin  or  steel,  according"  to  the  needs  of  the  case,  to 
maintain  the  proper  position,  prevent  stretching  or  contracture,  and 
to  allow  the  parts  to  be  used.  This  apparatus  is  to  be  removable 
so  that  the  systematic  massage,  electricity  and  exercise  can  be  kept 
up  daily.  This  plan  of  treatment  should  be  pursued  for  months, 
or  as  long  as  improvement  can  be  observed.    A  suitable  brace  for  a 

lower  extremity  is  made  of  steel  cov- 
ered with  leather.  It  consists  of  a 
steel  pelvic  band  having  an  upright 
extending  from  the  pelvic  band  to  the 
sole  of  the  shoe  on  the  outside,  and 
jointed  at  hip,  knee  and  ankle.  On  the 
inside  of  the  limb  there  is  an  upright, 
extending  from  the  perineum  to  the 
sole,  and  jointed  at  knee  and  ankle. 
The  two  uprights  are  connected  by  en- 
circling bands,  half  of  steel,  upon 
thigh  and  leg.  The  knee-joint  has 
a  sliding  ring  or  other  device  which 
locks  the  hinge  in  extension  when  the 
patient  stands.  On  sitting  he  un- 
locks it. 

With  most  cases  coming  to  the 
surgeon,  there  is  not  merely  paralysis, 
but  deformity  has  been  allowed  to 
develop.  It  is  the  deformity  which 
must  first  be  dealt  with.  Fig.  137  will 
serve  to  illustrate  the  bad  results  of 
infantile  paralysis  when  neglected.  The 
boy  was  five  years  old,  but  had  never 
walked,  the  disease  having  attacked  him 
early  in  his  second  year.  His  lower 
extremities  had,  as  usual,  suffered  the 
worst.  They  were  wasted,  cold,  and 
weak.  In  this  case  it  was  both  limbs, 
which  is  not  usual.  He  could  crawl, 
dragging  the  paralyzed  limbs.  Fig. 
137  shows  his  best  effort  at  stand- 
ing by  putting  the  strain  on  the 
ligaments  of  the  right  knee  in  over-extension,  and  leaning  on  the 
arms.  The  left  thigh  could  not  be  more  than  half  extended  because 
of  contraction  of  the  flexors.  The  left  sole  could  not  be  placed  on  the 
floor,  but  it  was  held  in  the  position  of  equinus  or  equino-varus 
by  the  shortening  of  the  unparalyzed  or  less  paralyzed  foot- 
extensors  at  the  back  of  the  leg.  Sub-luxation  backward  of  the  left 
tibia  upon  the  femur  had  taken  place.     Attempts  to  stand  upright 


Fig.  137.  Paralysis  from 
POLIOMYELITIS  in  the  second 
year.  He  could  not  walk 
nor  stand  without  support 
and  contractures  held  his 
left  limb  flexed  as  shown. 
Attempts  to  straighten  the 
limb  caused  lordosis. 


THE    PARALYSES    OF   INFANCY    AND    CHILDHOOD        401 

caused  lordosis  by  the  pull  of  the  contracted  thigh  muscles  upon 
the  pelvis. 

Obviously  it  would  be  impossible  in  such  a  case  to  overcome 
the  deformity  by  mechanical  appliances  of  any  kind.  Alonths  of 
time  and  the  expenditure  of  measureless  patience  would  result  in 
nothing  but  failure,  and  perhaps  add  pressure  ulceration  to  the 
trouble.    The  deformity  must  be  overcome  before  a  brace  is  applied. 


Fig.  138.  Same  case  as  Fig.  137  after 
tenotomies  had  enabled  him  to  bring  the 
left  limb  down  and  to  place  the  sole  upon 
the  floor.     Suitable  braces   are  shown. 


Fig.  139.  Same  case  as 
shown  in  Figs.  137  and 
138,  with  braces  applied. 
Boy  able  to  walk. 


The  contracted  tendons  of  the  thigh,  and  also  the  tendo  x\chillis, 
were  released  by  tenotomies,  so  that  the  boy  could  take  the  position 
shown  in  Fig.  138,  with  both  soles  on  the  floor,  the  thigh  much  bet- 
ter extended,  and  the  lordosis  improved.  But  the  muscles  needed 
aid  to  support  the  weight  and  control  position,  and  so  braces  were 
supplied.  The  limbs  being  now  in  position  for  locomotion,  active 
exercise,  supplemented  by  hot  bathing  and  massage,  began  to  im- 
prove them  so  that  he  soon  walked  very  well.     Almost  every  case 


402 


SURGICAL  DISEASES    OF   CHILDREN 


of  infantile  paralysis  can  be  improved  and  the  patient  be  made  to 
walk  or  to  use  the  arm  if  deformity  be  overcome  and  the  part  be 
maintained  in  a  position  to  be  used.  If  it  is  the  lower  extremity 
that  is  paralyzed,  the  brace  has  two  functions  to  perform:  to  put 
the  joints  in  such  position  that  the  muscles  are  balanced,  and  to  sup- 
port weight.  For  instance,  in  the  case  shown  in  Fig.  138  the  left 
knee  must  be  held  in  extension,  for  the  extensor  is  paralyzed;  and 
the  right  must  be  prevented  from  over-extension  and  maintained 

in  extension,  for  both  flexors  and  exten- 
sors are  almost  entirely  paralyzed.  But 
there  is  sufficient  power  to  maintain  the 
pelvis  balanced  upon  the  femurs  and  to 
swing  forward  the  limbs  in  walking, 
provided  they  are  maintained  in  the  ex- 
tended position  and  enabled  to  bear  the 
weight.  Suitable  braces  are  shown  in 
Figs.  138  and  139.  There  are  numerous 
modifications.  Fig.  140  applies  this 
principle  to  ankles  in  which  the  muscles 
of  the  leg  are  paralyzed,  and  allow 
the  sole  of  the  foot  to  turn  when 
weight  is  put  upon  it.  (See  Fig.  141.) 
A  flat-foot  plate  under  the  sole  with  a 
brace  to  reach  up  the  leg  to  an  encircling 
band  below  the  knee  holds  the  foot 
squarely  under  the  leg,  where  it  bears  the  weight  of  the  body  in 
walking.  Sometimes  a  strong,  well-fitting  laced  shoe  may  have  a 
brace  attached,  with  a  joint  that  does  not  allow  extension  of  the  foot 
beyond  a  right  angle,  but  allows  flexion  in  walking.  A  toe  lift  in 
the  shape  of  a  spring  or  a  rubber  muscle  may  be  added  if  the  an- 
terior muscles  are  paralyzed  so  that  there  is  a  tendency  to  drag  the 
toe.  In  other  cases  it  is  necessary  to  have  an  upright  at  each  side 
of  the  foot  instead  of  only  upon  one  side,  reaching  up  to  the  leg- 
band,  of  which  half  its  circle  is  of  steel,  leather  covered.  Such  a 
brace  with  the  artificial  muscle  in  front,  is  useful  not  only  in  weak 
ankle,  but  in  all  deformities  in  which  there  is  a  tendency  to  equi- 
nus.  In  club-foot  from  paralytic  contractions  the  contracted  ten- 
dons should  be  released  in  the  same  manner  as  for  congenital  club- 
foot. In  equinus  the  tendo  Achillis  is  at  fault  and  must  be  severed 
or  lengthened  or  part  of  it  transplanted,  unless  nerve  transference 
can  be  planned  and  performed.  (See  Fig.  142.)  In  cases  of 
equino-varus  the  tendo  Achillis  and  sometimes  the  tibiales,  and  it 
may  be  also  the  plantar  fascia,  will  require  division.  In  the  less 
common  form,  calcaneo-valgus,  the  peroneals  will  need  tenotomy. 
In  calcaneus  the  tendo  Achillis  should  be  shortened.  (See  Club- 
foot.) 


Fig. 


140.     Weak- ANKLE 

BRACE. 


THE    PARALYSES    OF   INFANCY    AND    CHILDHOOD         403 

The  technique  of  tenotomy,  and  tendon  shortening  and  length- 
ening, will  be  found  in  the  section  on  the  tendons. 

It  is  useless  to  perform  either  tendon  shortening  or  lengthen- 
ing if  the  muscle  connected  with  the  tendon  is  completely  paralyzed. 
If  the  muscle  has  but  slight  power,  putting  it  to  use  will  improve 
it.  Otherwise  a  simple  tenotomy  will  relieve  the  contracture  as 
well  as  a  tendon  lengthening ;  and  a  shortened  completely  para- 
lyzed tendon  will  require  also  arthrodesis  to  show  any  appreciable 
result. 

Arthrodesis. — In  complete  paralysis  of  muscles  controlling  foot 
or  leg  or  thigh,  causing  "  flail-joint  "  at  the  ankle,  at  the  knee  or  at 


Fig.  141.     Poliomyelitis  in  infancy.     One  left  and  one  right  leg  paralyzed, 
so   that  the   ankle  yields   laterally.     Children  now   in   twelfth   year. 

the  hip,  the  operation  of  arthrodesis  is  sometimes  performed  with 
the  object  of  causing  ankylosis  of  the  joint,  in  such  position  as  will 
support  the  weight  of  the  body  and  permit  walking.  It  has  also 
been  occasionally,  although  far  less  frequently,  performed  at  the 
elbow  or  wrist  than  at  the  ankle.  The  operation  is  very  similar  to 
erasion  or  atypical  resection,  but  more  easily  done,  for  there  is  no 
diseased  tissue  to  look  for  and  remove.  For  each  joint  the  mode  of 
opening  is  selected  which  seems  best  suited  to  the  individual  case. 
If  tendons  or  ligaments  are  better  upon  one  side,  that  side  is  spared, 
and  the  over-stretched  tendons  or  ligaments  upon  the  side  opened 
are  shortened  in  the  closing.  In  the  ankle  this  operation  finds  its 
most  useful  application.    The  usual  incision  is  anterior.    Some  oper- 


404  SURGICAL   DISEASES    OF   CHILDREN 

ators  prefer  the  posterior,  or  one  or  the  other  lateral,  according  to 
conditions.  In  the  knee  the  incision  is  anterior,  through  the  patella. 
After  the  joint  is  opened,  with  a  knife,  gouge  or  Volkmann  spoon, 
the  cartilage,  or  a  portion  of  it,  is  removed.  It  is  not  necessary  to 
remove  all  of  the  cartilage  nor  synovial  membrane.  In  closing,  the 
severed  tendons  and  ligaments  are  carefully  replaced  and  united, 
and  no  drainage  unless  a  strand  of  catgut  is  employed.  After  the 
antiseptic  dressing,  a  plaster  case  is  applied  and  the  joint  immobil- 
ized for  one  or  two  months.  Fibrous  ankylosis  is  expected.  If 
both  knee  and  ankle  in  the  same  limb  are  flail-like,  both  will  require 

the  operation,  or  an 
apparatus  can  be  worn 
for  the  knee.  Children 
do  better  under  this 
operation  than  those 
past  puberty.  In  many 
such  cases  it  is  a  ques- 
tion whether  amputa- 
tion is  not  preferable. 
The  condition  of  the 
psoas  and  iliacus  should 
always  be  considered. 
If  the  limb  cannot  be 
swung  forward  it  is 
not  of  much  use  even 
if  the  joints  are  stif- 
fened to  support  the 
weight.  The  circula- 
tion and  the  condition 
of  the  skin  as  to  ulcer- 
ation and  tendency  to 
sores  and  chilblains, 
should  be  taken  into 
account.  Some  patients 
would  prefer  to  wear  apparatus  rather  than  have  an  ankylosed  knee- 
joint,  which  cannot  be  bent  on  sitting  down. 

Arthrodesis  of  the  hip  is  not  to  be  thought  of  unless  the  joint 
is  so  readily  luxed  spontaneously  as  to  be  useless.  Even  then  strong 
ankylosis  is  not  always  obtained. 

Contraction  deformities  of  the  hip-joint  resulting  from  polio- 
myelitis are  a  difficult  class  of  cases  to  treat.  Some  cases  will  yield 
to  the  weight  and  pulley,  or  to  this  if  preceded  with  a  few  tenoto- 
mies. But  when  the  deep-seated  tendons  and  the  fascise  and  the 
ligaments  are  all  permanently  contracted  it  requires  extensive  oper- 
ative work  to  release  them.  Under  these  conditions  osteotomy  of 
the  femur  close  below  the  lesser  trochanter  is  preferable.    The  tech- 


FiG.  142.  Hammertoe, 
caviis,  with  equinus. 
myelitis.  Case  of 
McCurdy. 


approximating  pes 
Result  of  polio- 
Dr.      Stewart     L. 


THE   PARALYSES    OF   INFANCY   AND   CHILDHOOD        405 

nique  of  osteotomy  is  described  in  the  chapter  on  rickety  deformities. 
In  the  thigh  the  incision  would  be  upon  the  outer  side. 

In  the  knee  the  most  common  deformity  is  flexion,  or  this  with 
sub-luxation  backward.  If  flexion  only,  it  may  frequently  be  over- 
come by  the  use  of  a  Thomas  knee  splint,  applying  an  elastic  bandage 
or  even  a  flannelette  roller  over  the  knee,  tightening  it  a  little  every 
day.  Traction  with  weight  and  pulley  will  also  often  succeed.  In 
other  cases  it  is  necessary  to  tenotomize.  If  there  is  also  sub-luxa- 
tion these  methods  will  not  answer.  Weight  and  pulley  to  the  leg 
may  be  used  if  a  second  one  be  applied  to  the  upper  end  of  the  tibia 
to  pull  forward  the  head  of  the  bone.  Or  a  splint  resembling  the 
Thomas  knee  splint,  with  a  band  to  press  forward  on  the  tibial  head 
and  another  to  press  backward  upon  the  lower  end  of  the  femur, 
may  be  used.  Or  forcible  straightening  may  be  performed,  either 
by  manual  force  or  the  aid  of  a  Peters  or  Goldthwaite  or  other  pat- 
tern of  genuclast. 

Tendon  Transplantation. — Modern  surgeons  have  not  been  con- 
tented with  mechanical  aids  to  locomotion,  with  arthrodesis,  correc- 
tion of  deformities  by  tenotom}^,  with  tendon  lengthening  or  short- 
ening. They  have  attempted,  successfully,  to  substitute  healthy  mus- 
cles for  paralyzed  by  the  procedure  known  as  tendon  transplanta- 
tion. The  principles  and  the  technique  of  this  procedure  are  dis- 
cussed in  a  general  section  on  the  subject  in  a  previous  chapter. 
Tendon  transplantation  often  finds  application  in  poliomyelitis,  in 
which  often  a  single  muscle  or  group  of  muscles  may  be  paralyzed, 
and  sound  or  nearly  sound  muscles  have  their  tendinous  attachments 
within  reach.  Each  case  must  be  carefully  studied  and  the  work 
planned  to  suit  it.  A  few  examples  will  be  cited  by  way  of  illustra- 
tion. With  paralysis  of  both  tibiales  the  foot  is  everted  and  flat- 
tened and  the  patient  treads  upon  its  inner  border.  If  the  extensor 
proprius  hallucis  is  healthy  its  tendon  can  be  cut  and  transplanted 
to  the  periosteum  of  the  inner  side  of  the  scaphoid.  To  supplement 
its  action  the  tendon  of  the  peroneus  longus  may  be  cut  at  the  outer 
border  of  the  foot,  drawn  out  through  an  incision  behind  and  above 
the  outer  maleolus  and  drawn  through  a  tunneled  opening  beneath 
the  tendo  Achillis,  and  attached  to  a  groove  beneath  the  periosteum 
of  the  scaphoid.  Or  with  the  same  condition  of  valgus  or  equino- 
valgus  from  paralysis  of  both  tibiales,  the  peroneus  brevis  may  be 
transplanted  as  just  described  for  the  peroneus  longus,  and  the  pero- 
neus tertius  be  carried  under  the  tendons  in  front  of  the  ankle  and 
also  inserted  into  the  scaphoid.  Or,  with  paralysis  of  the  tibialis 
anticus  the  tendon  of  the  extensor  pollicis  may  be  divided  and  so 
transplanted  as  to  take  the  work  of  the  paralyzed  muscle. 

With  paralysis  of  the  gastrocnemius  and  soleus  we  get  calca- 
neus ;  the  peronei  remaining  healthy,  the  latter  may  be  transjilanted 
and  made  to  do  the  duty  of  the  former.    The  tendo  Achillis  should 


4o6  SURGICAL   DISEASES    OF    CHILDREN 

be  shortened.  If  pes  cavus  also  exists  with  over-action  of  the  ante- 
rior tibial  group,  this  deformity  should  be  forcibly  corrected  at  the 
same  time.  Conversely,  with  paralysis  of  the  peronei,  the  gastroc- 
nemius remaining  unparalyzed,  the  tendo  Achillis  may  spare  its  outer 
half,  which  is  detached  from  its  insertion,  split  upward  a  distance 
of  two  or  more  inches,  and  by  having  its  length  augmented  with 
strands  of  heavy  silk,  be  inserted  into  the  outer  side  of  the  cuboid, 
and  be  made  to  abduct  and  evert  the  foot. 

Likewise  the  inner  half  of  the  tendo  Achillis  may  be  carried 
around  the  inner  side  of  the  joint  and  sutured  to  the  tendon  of  the 
paralyzed  tibialis  anticus ;  or  a  better  procedure,  the  transplanted 
sound  tendon  may  be  lengthened  by  silk  and  inserted  into  the  peri- 
osteum on  the  inner  border  of  the  foot. 

Of  the  muscles  which  move  the  leg  upon  the  thigh,  that  most 
frequently  paralyzed  is  the  quadriceps  extensor.  This  has  been 
successfully  treated  by  transplanting  the  hamstring  tendons  forward 
to  the  tendon  of  the  extensor,  or  with  silk  grafts  extending  them  to 
the  anterior  surface  of  the  head  of  the  tibia.  Before  resorting  to 
this  procedure  it  should  be  ascertained  whether  the  gastrocnemius 
is  sufficiently  strong  to  accomplish  flexion.  If  it  is  not  thought  best 
to  spare  the  hamstrings  from  their  normal  situations,  the  tensor 
vaginae  femoris  and  the  sartorius,  being  transplanted  to  the  quadri- 
ceps, can  be  utilized  as  extensors  of  the  leg.  It  should  be  men- 
tioned that  after  transplantation  of  the  hamstrings  over-extension 
of  the  knee  has  occurred  in  some  instances. 

The  foregoing  are  but  examples  of  the  application  of  tendon 
transplantation.  The  variations  that  are  resorted  to  are  as  numerous 
as  the  varying  distribution  of  the  paralysis,  and  more  so.  There  are 
scores  of  them. 

In  all  cases  the  technique  as  described  in  the  general  section 
must  be  observed.  The  joint  must  be  held  in  over-correction  and 
the  transplanted  tendon  must  be  taut  when  it  is  attached  to  its  inser- 
tion. In  operations  near  either  knee  or  foot  both  joints  should  al- 
ways be  included  in  the  plaster  bandage.  Otherwise  immobility  is 
not  assured. 

Nerve  Transference. — The  general  subject  of  nerve  transfer- 
ence and  nerve  suture  has  been  discussed  in  another  section.  It 
has  an  application  in  the  treatment  of  paralysis  following  poliomye- 
litis. An  example  is  one  of  Murphy's  cases. ^  The  paralysis,  of  five 
years'  standing,  was  limited  to  the  anterior  tibial  and  extensor  com- 
munis digitorum  muscles.  An  anastomosis  was  made  between  the 
external  and  internal  popliteal  nerves.  A  tendo-plastic  operation  also 
was  performed,  the  flexors  being  elongated  and  the  extensors  short- 
ened. The  result  was  great  improvement.  Electrical  response  re- 
turned to  the  extensors  and  the  patient  was  able  to  walk  and  to  run. 

1  Magazine  of  Surg.,  Gynec.  and  Obst.,  April,  1907. 


THE   PARALYSES    OF   INFANCY   AND    CHILDHOOD        407 

Another  example  is  implantation  of  two-thirds  of  the  peroneal 
branch  of  the  musculo-cutaneous  into  the  anterior  tibial.  Conversely, 
an  anastomosis  may  be  formed  between  the  anterior  tibial  and  the 
musculo-cutaneous.  (Spiller  and  Frazier.^)  There  are  many  dif- 
ficulties in  the  way  of  nerve  transference  in  paralysis  in  the  same 
quarter  of  the  body.  But  many  of  them  will  be  overcome  by  fur- 
ther study  and  experiment.  Murphy  draws  attention  to  the  cauda 
as  a  zone  wherein  the  lower  sacral  and  lumbar  nerves  are  in  close 
proximity,  and  could  be  joined  to  neighboring  fibers,  or  to  roots  on 
the  opposite  side  of  the  cord. 

CEREBRAL    PARALYSES 

Infantile  Cerebral  Paralysis  (Spastic  Paralysis,  Spastic  Di- 
plegia, Paraplegia  or  Hemiplegia). — The  accumulated  literature 
upon  this  subject  is  voluminous  and  still  augmenting,  and  I  can  only 
present  here  a  brief  outline  which  has  a  bearing  upon  the  practical 
surgery  of  the  condition.  There  is  much  confusion  in  the  earlier 
descriptions,  and  more  recent  studies  have  not  yet  solved  all  the 
problems  pertaining  to  the  subject. 

There  are  a  number  of  causes  connected  with  malformation 
of  the  brain,  and  fetal  disease  of  the  brain  so  early  in  fetal  life  and 
so  obscure  as  to  be  in  many  instances  untraceable. 

In  another  class  of  cases  the  brain  was  originally  normal  in  de- 
velopment and  health  up  to  the  hour  of  birth,  when  accidental  injury 
resulted  in  changes  accompanied  by  spastic  paralysis. 

In  a  third  class  of  cases  the  brain  was  normal  in  development 
and  escaped  the  dangers  incident  to  birth,  but  later,  from  accident 
or  disease,  became  disabled  in  its  motor  and  probably  in  other  areas. 
Now  it  is  the  second  and  third  class  of  cases,  and  particularly  the 
second,  the  birth  palsies,  that  present  the  greatest  surgical  interest, — 
an  interest  which  I  believe  will  increase  with  further  surgical  study 
of  the  subject, — and  yet  it  is  necessary  for  us  to  consider  somewhat 
all  three  groups  of  cases.  None  of  them  are  to  be  looked  upon  as 
an  active  disease,  but  rather  as  a  result  of  developmental  fault,  or 
of  injury,  or  of  disease,  which  has  already  at  some  time  in  the  past 
done  its  worst,  since  which  time  nature  has  endeavored  to  deal  with 
the  consequences.  It  should  be  understood  that  it  is  only  one  promi- 
nent symptom  that  has  given  the  name  to  the  disease,  and  that  tliere 
are  often  other  symptoms,  such  as  idiocy  or  epilepsy  in  connection; 
and  that  no  classification  is  at  the  present  time  scientific  either  from 
an  etiological  or  clinical  standpoint. 

Paralysis  from  Pre-Natal  Causes. — In  these  cases  there  is 
defective  formation  of  brain  tissue,  microccphalus,  porencephalus, 
or  the  results  of  fetal  intracranial  hemorrhage  or  thrombosis.    Some 

1  Jour.  Am.  Med.  Assn. 


4o8  SURGICAL   DISEASES    OF   CHILDREN 

cases  have  been  attributed  to  lowering  disease  of  the  mother,  or  to 
injury  of  the  mother  during  pregnancy.  In  some  cases  there  is  no 
gross  lesion  of  brain,  but  a  failure  of  development  of  the  cells  of  the 
cortex.  The  results  vary  according  to  the  stage  of  the  development 
of  the  fetus  when  the  arrest  took  place  and  to  the  location  and  ex- 
tent of  hemorrhage  or  thrombosis. 

Symptoms. — These  cases  usually  present  a  variety  of  symptoms 
more  prominent  than  the  motor  paralysis.  There  is  usually  feeble- 
mindedness or  idiocy  in  some  degree.  There  is  sometimes,  but  not 
always,  abnormally  small  or  asymmetrical  cranium.  And  there  is 
frequently  some  other  malformation  besides  that  of  the  brain.  The 
paralysis  is  usually  widely  distributed  and  either  diplegic  or  para- 
plegic. When  the  cortical  portion  generally  has  failed  of  develop- 
ment the  spastic  feature  does  not  accompany  the  paralysis.  The 
muscles  are  flaccid.  In  other  cases  there  is  rigidity  and  apt  to  be 
convulsions. 

Paralysis  from  Birth  Injuries  (Birth  Palsies;  Little's 
Disease). — In  this  important  and  interesting  class  of  cases,  the  con- 
dition results  from  meningeal  or  intra-cerebral  hemorrhage  in  an 
infant  at  or  about  full  term  or  in  the  act  of  birth.  There  may  be 
present  only  that  predisposition  to  hemorrhage  which  seems  normal 
to  the  fetus  at  term,  or  a  distinct  hemorrhagic  blood  dyscrasia  which 
is  thought  to  be  due  in  some  cases  to  an  unknown  infection,  in 
others  undoubtedly  to  syphilis.  The  exciting  cause  is  injury  before 
or  more  frequently  during  labor.  This  may  arise  in  cases  of  undue 
or  prolonged  pressure  upon  the  head,  premature,  precipitate,  or  de- 
layed delivery,  or  forceps  delivery,  delay  in  head-last  cases,  and 
asphyxia  livida  from  any  cause.  In  many  cases  there  is  cephal- 
hematoma and  in  a  few  demonstrable  cranial  fracture.  The  hem- 
orrhage varies  greatly,  both  in  amount  and  in  location.  There  may 
be  only  a  drachm  or  two,  or  several  ounces.  This  may  be  diffuse 
or  all  in  one  mass.  It  frequently  comes  from  the  vessels  of  the  pia- 
mater,  or  a  cerebral  vein,  or  more  rarely  a  sinus,  or  a  vessel  travers- 
ing a  cranial  foramen.  Therefore  it  may  be  beneath  the  pia  or  be- 
tween pia  and  dura,  or  between  dura  and  skull.  The  blood  is  more 
frequently  found  at  the  base  and  posteriorly,  but  it  may  occur  over 
the  convexity,  especially  over  the  occipital  lobes  of  the  cerebrum. 

Hemorrhage  may  lead  to  softening,  or  set  up  a  meningitis,  or 
gradually,  by  pressure,  after  months  or  years  lead  to  atrophy  of  the 
brain,  sclerotic  changes,  and  sometimes  cystic  degeneration.  The 
sclerosis  consists  in  proliferation  of  the  neuroglia,  thickening  of 
the  walls  of  the  vessels,  and  hypertrophy  of  the  connective  tissues 
all  about  them,  while  the  nervous  elements  diminish  or  disappear. 
The  sclerosis  may  be  localized  in  tuberous  shaped  portions  or  dif- 
fused over  one  of  the  cerebral  hemispheres.     But  it  may  be  impos- 


THE   PARALYSES    OF   INFANCY    AND    CHILDHOOD        409 

sible  in  making  an  autopsy  upon  a  case  of  spastic  paralysis  to  state 
whether  the  original  cause  was  a  cerebral  hemorrhage  or  meningo- 
encephalitis or  embolism.  Nor  is  it  always  possible  to  say  whether 
it  was  secondary  to  any  of  these  or  was  an  arrest  of  development. 
What  Sachs  calls  agnesia  corticalis,  considering  it  a  failure  of  devel- 
opment of  the  cells  of  the  cortex,  Oppenheim  attributes  in  many  in- 
stances to  changes  secondary  to  meningeal  hemorrhage.  Porenceph- 
alia may  occur  in  connection  with  the  sclerosis  or  independently  of 
it;  and  like  it  may  be  looked  upon  as  an  error  of  development  or  as 
secondary  to  intra-uterine  disease  or  to  an  injury  or  disease  acquired 
at  or  after  birth.  The  cysts  are  usually  about  the  size  of  a  walnut, 
and  are  apt  to  be  located  in  the  central  and  temporal  convolutions,  but 
may  occupy  nearly  as  much  of  a  hemisphere  as  is  supplied  by  the 
middle  cerebral  artery  and  the  artery  of  the  Sylvian  fissure.  De- 
generations also  of  the  internal  capsule  and  the  lateral  columns  of 
the  cord  are  frequently  found. 

Symptoms. — An  extensive  hemorrhage  taking  place  either  be- 
fore or  during  labor  may  cause  death.  Or  the  infant  may  be  born 
alive  but  asphyxiated,  and  even  when  resuscitated  remain  lethargic, 
with  shallow  or  irregular  respiration,  and  feeble  and  slow  pulse. 
He  can  scarcely  be  induced  to  nurse.  He  may  sink  gradually  and 
die  after  a  few  hours ;  or  may  rally  and  develop  rigidities  of  the 
muscles  of  the  extremities,  retraction  of  the  head  with  contracted 
pupils  and  nystagmus,  increased  patellar  reflex,  sometimes  general 
convulsions.  It  is  probable  in  such  a  case  that  the  hemorrhage  is 
over  the  cortex.  It  is  after  hemorrhage  at  the  base  that  coma  with 
paralysis  of  respiration  causes  death  without  convulsions  or  other 
motor  disturbances.  In  many  cases  it  is  difficult  to  acertain  whether 
paralysis  is  present,  or  will  follow.  In  some  it  may  be  observed  that 
a  leg  or  an  arm  or  the  face  is  paralyzed ;  or  the  convulsions  or  auto- 
matic movements  may  be  confined  to  one  part,  showing  irritation 
at  the  corresponding  cortical  center,  to  be  followed  later  by  paraly- 
sis. Occasionally  definite  hemiplegia,  diplegia  or  monoplegia  can 
be  demonstrated.  Many  cases  are  undetected  until  the  child  is  old 
enough  to  make  voluntary  movements. 

Diagnosis. — The  main  diagnostic  symptoms  of  the  recent  case 
are  succinctly  listed  by  Holt  as  "  stupor,  rigidity,  increased  reflexes, 
convulsions,  paralysis,  and  opisthotonos."  The  nystagmus,  con- 
tracted, dilated  or  unequal  pupils,  sighing,  irregular  respiration,  a 
bulging  fontanel,  may  also  be  present.  Often  there  is  corroborative 
evidence  in  a  cephalhematoma,  a  fractured  skull,  a  history  of  breech 
presentation,  tedious  labor,  asphyxia  at  birth  and  other  probable 
causes.  The  presence  of  a  group  of  the  symptoms  detailed,  in  a 
new-born  infant  or  one  apparently  normal  and  of  full  term  devel- 
opment, justifies  the  diagnosis  of  intracranial   hemorrhage.     But 


410  SURGICAL   DISEASES    OF   CHILDREN 

with  a  small  and  cachectic  babe,  or  one  evidently  premature,  or 
syphilitic,  or  with  a  microcephalic  or  hydrocephalic  or  asymmetrical 
cranium,  or  spina  bifida,  or  other  deformity,  one  would  hesitate  even 
in  the  presence  of  several  of  these  symptoms  to  make  a  diagnosis  of 
hemorrhage.  The  cases  which  survive  four  or  five  days  will  prob- 
ably live  to  develop  the  secondary  changes  and  exhibit  symptoms 
according  to  the  extent  and  location  of  the  lesion.  The  paralysis 
may  be  hemiplegic,  diplegic,  paraplegic,  or,  very  rarely,  monoplegic. 
Of  150  cases  reported  by  Osier,  120  were  hemiplegic,  19  diplegic, 
and  1 1  paraplegic.  Holt  believes  that  the  original  cases  of  diplegias 
and  paraplegias  outnumber  the  cases  of  hemiplegia  more  than  four 
to  one ;  but  that  many  of  the  former  die  during  the  first  two  years, 
while  the  hemiplegics  live  to  develop  the  results  of  the  lesions  and 
come  under  the  observation  of  neurologists  and  surgeons.  During 
infancy  there  may  be  more  or  less  rigidity  of  the  muscles  of  the  ex- 
tremities, particularly  of  the  lower  extremities,  and  sometimes  of 
the  neck  and  trunk,  with  occasional  attacks  of  convulsions.  There 
may  be  noticeable  backwardness  in  growth  and  development,  physi- 
cal and  mental,  the  babe  not  learning  to  hold  up  his  head  or  to  sit 
up  or  to  grasp  objects  or  to  make  attempts  to  stand  at  the  age  when 
normal  infants  do.  Or  the  condition  may  be  so  slight  as  to  pass 
unnoticed  or  considered  mere  backwardness  until  the  child  is  two 
or  four  or  five  years  old.  Then  the  condition  varies  greatly  in 
degree.  A  severe  case  may  be  bilateral — a  bilateral  hemiplegia — 
with  spastic  rigidity  of  the  extremities,  probably  much  less  marked 
in  the  upper  than  in  the  lower.  The  legs  may  be  crossed  and  so 
rigid  as  to  prevent  the  patient  from  walking.  If  he  does  walk  it  is 
with  a  stiff  and  jerking  gait.  He  drags  the  limb  and  circumducts 
it  in  advancing  the  foot.  The  feet  may  be  rigidly  held  in  equinus 
or  equino-varus.  The  hands,  especially,  are  liable  to  athetoid  or 
irregular  choreic  movements,  often  with  the  fingers  closed  over  the 
thumb.  These  movements  affect  also  the  neck  or  the  muscles  of 
middle  and  lower  parts  of  the  face.  The  rigidities  yield  gradually 
to  steady  pressure.  The  cranium  may  be  small  or  misshapen.  Fre- 
quently the  mouth  is  large  and  kept  open,  with  the  saliva  dribbling. 
The  teetli  are  large  and  irregular.  There  is  mental  impairment 
often  amounting  to  partial  idiocy;  but  it  often  is  of  a  higher  grade 
than  one  would  expect  from  appearances.  The  tendon  reflexes  are 
exaggerated.  Electrical  reactions  are  normal.  Epilepsy  develops  in 
nearly  half  of  the  cases. 

Acute  or  Subacute  Acquired  Cerebral  Paralysis. — This 
class  of  cases  occurs  in  children  originally  normal  and  born  without 
accident.  As  a  result  of  whooping-cough,  or  of  one  of  the  exan- 
themata, or  diphtheria,  or  pneumonia,  or  more  rarely  of  traumatism, 
and  sometimes  without  discoverable  cause,  hemiplegia  appears. 
More  rarely  it  is  diplegia  or  paraplegia. 


THE    PARALYSES    OF   INFANCY   AND    CHILDHOOD        411 

Lesions. — The  lesions  may  be  found  in  the  blood-vessels,  or  in 
the  membranes  of  the  brain.  But  if  a  hemorrhage  it  is  more  apt  to 
occur  over  the  convexity  than  in  hemorrhage  at  birth.  Hemorrhage 
may  initiate  or  may  result  from  meningitis.  Sinus  thrombosis  and, 
more  rarely,  embolus,  may  be  associated  with  it.  Whether  the  pri- 
mary lesion  is  of  blood-vessels  or  of  the  meninges,  the  effect  upon 
the  brain  substance  is  much  the  same  as  has  been  described  in  birth 
palsy,  namely,  atrophy  and  sclerosis,  with  secondary  degeneration 
in  the  cord. 

Syniptoins. — A  typical  primary  case  is  ushered  in  by  fever,  con- 
vulsions, often  with  vomiting,  and  followed  by  coma  or  delirium. 
These  symptoms  continue  for  several  days,  when  paralysis  is  discov- 
ered, usually  hemiplegic.  In  secondary  cases  there  may  be  only 
convulsions,  and  perhaps  coma,  in  addition  to  the  symptoms  of  the 
primary  disease.  Occasionally  the  coma  or  general  paralysis  results 
in  death.  The  cases  that  recover  present  spastic  paralysis  with  in- 
creased reflexes  on  the  affected  extremities.  The  paralysis  may  im- 
prove considerably  in  the  course  of  a  few  weeks.  The  speech  center 
may  be  aftected,  and,  curiously,  this  occasionally  occurs  in  right- 
sided  brain  lesions  as  well  as  left-sided  in  infants.  After  a  few 
years,  atrophy  of  affected  muscles  and  contractures  may  result.  As 
in  birth-palsy,  epilepsy  and  irregular  choreiform  or  athetoid  move- 
ments are  common  sequellse.  The  mental  condition  is  very  much 
less  likely  to  be  affected  than  in  birth-palsy. 

Prognosis  in  All  Forms  of  Infantile  Cerebral  Paralysis. — Three 
factors  enter  into  the  prognosis.  The  stage  of  development  of  the 
brain  when  the  lesion  occurs,  and  the  extent,  and  the  location  of  the 
lesion.  Those  injured  or  diseased  in  fetal  life  are  apt  to  be  seriously 
damaged,  and  many  of  them  do  not  survive  infancy.  Those  in 
whom  the  lesion  is  so  extensive  as  to  produce  diplegia  or  paraplegia 
may  be  placed  in  the  same  class  as  regards  prognosis.  If  any  of 
them  survive  they  are  seriously  defective  mentally  and  practically 
helpless  physically  on  account  of  spastic  paralysis  of  the  extremi- 
ties. When  the  lesion  has  been  of  less  extent  and  resulted  only  in 
hemiplegia  there  is  prospect  not  only  of  life  but  of  a  degree  of  useful- 
ness. The  older  the  child,  and  therefore  the  more  advanced  the 
cerebral  development  at  the  time  of  the  paralytic  attack,  the  less 
serious  is  the  resulting  damage  to  mind  and  motor  centers.  In  an 
infant  it  is  possible  for  speech  to  be  restored  after  having  been 
destroyed  by  a  lesion  in  the  left  side  of  the  brain,  the  right  side  ap- 
parently acting  as  a  speech  center.  The  probability  of  the  develop- 
ment of  epilepsy  should  be  borne  in  mind.  It  is  impossible  to  predict 
in  infancy  what  the  degree  of  mental  development  will  be.  Ordi- 
narily there  is  a  tendency  toward  improvement.  Much  can  be  done 
by  education  and  training,  both  for  the  mind  and  for  the  body,  and 
an  improvement  of  the  physical  condition  and  the  motor  control  by 


412  SURGICAL   DISEASES    OF    CHILDREN 

surgical  means  seems  to  react  very  favorably  on  the  mental  state. 
The  less  the  mental  deficiency  the  greater  will  be  the  practical  ben- 
efit from  surgical  interference  for  the  improvement  of  the  deformity. 

Diagnosis. — In  the  acute  stage  of  the  acquired  form,  it  may  be 
impossible  to  distinguish  between  hemorrhage  and  meningitis 
secondary  to  another  disease.  If  hemorrhage  follows  trauma  it 
would  likely  supervene  earlier  than  a  meningitis  would  have  time  to 
develop.  Early  loss  of  consciousness  and  early  and  permanent  par- 
alysis point  toward  hemorrhage  rather  than  meningitis.  Character- 
istic symptoms  of  cerebral  paralysis  are  its  distribution,  being  diple- 
gic  or  hemiplegic,  the  presence  of  rigidity  which  slowly  yields  to 
pressure,  exaggerated  reflexes,  slow  atrophy,  and  finally  the  unal- 
tered electrical  reactions.  Corroborative  evidence  may  be  found  in 
the  psychic  symptoms  and  the  paralysis  of  the  facial  and  motor  oc- 
culi,  and  in  the  history.  Paralysis  of  poliomyelitis  is  confined  to 
certain  muscle  groups,  or  even  a  single  muscle ;  has  the  reflexes 
absent ;  rigidit}'  if  present  is  permanent,  and  will  not  yield  to  pres- 
sure in  a  short  time ;  the  paralyzed  extremity  is  cold,  reaction  of 
degeneration  is  present,  and  there  are  no  head  symptoms.  In  pres- 
sure paralysis,  for  instance,  that  accompanying  spinal  caries,  there 
are  pain  and  usually  deformity,  spinal  rigidity,  and  no  cerebral 
symptoms.  In  beginning  pseudo-hypertrophic  paralysis  if  the 
past  history  does  not  make  the  diagnosis  clear,  the  future  will 
do  so. 

Treatment. — The  treatment  of  the  ante-natal  cases  can  only 
be  prophylactic,  and  resolves  itself  into  treatment  of  syphilis  if  that 
disease  is  present,  and  hygienic  care  and  safeguarding  of  the  preg- 
nant woman  in  all  cases.  The  prophylaxis  of  hemorrhage  during 
birth  rests  with  the  obstetrician,  in  shortening  labor  and  avoiding 
undue  or  prolonged  pressure  upon  the  head.  Intracranial  hemor- 
rhage in  the  new-born  has  never  received  the  attention  from  the 
profession  that  it  deserves.  Many  cases,  doubtless,  with  hemor- 
rhages at  the  base  or  in  inaccessible  locations,  are  beyond  the  aid  of 
surgery.  But  those  not  resulting  fatally  within  a  few  days,  among 
which  are  a  large  number  with  the  hemorrhage  over  the  convexity, 
should,  if  the  diagnosis  can  be  made  and  the  situation  of  the  clot 
localized  with  reasonable  certainty,  have  an  effort  made  for  their 
relief  by  trephining  and  removal  of  the  clot.  (See  Section  on 
Operations  upon  the  Cranium.)  There  is  no  denying  the  danger 
of  such  a  procedure,  and  yet  without  relief  the  result  is  distressing 
and  sometimes  worse  than  death.  The  diagnosis  and  accurate  local- 
ization are  often  difficult ;  and  yet  I  think  with  care  and  attention 
these  could  both  be  accomplished  in  a  large  number  of  cases. 
Otherwise  nothing  can  be  done  immediately  after  the  hemorrhage 
but  to  keep  the  babe  quiet  and  await  developments.     Convulsions, 


THE    PARALYSES    OF    INFANCY    AND    CHILDHOOD        413 

meningitis,  fever,  or  vomiting  supervening  are  to  be  treated 
symptomatically.  The  same  may  be  said  of  the  acute  stage  of  ac- 
quired paralysis.  But  later  the  treatment  of  the  resulting  condi- 
tions is  by  educational  methods,  massage,  passive  and  active  move- 
ments, gymnastics  and  electricity.  Faradic  electricity  is  recom- 
mended to  be  used  daily.  When  the  spastic  contractions  prevent 
placing  the  parts  in  position  for  proper  use  they  should  be  relieved 
by  tenotomies,  myotomies  and  fasciotomies  in  the  same  manner  as 
described  for  spinal  paralysis.  It  is  usually  useless  to  attempt  cor- 
rection by  the  use  of  braces  without  operation.  Pain  and  ulceration 
would  ensue  and  no  permanent  correction  of  the  spasm  be  accom- 
plished. Tenotomy,  besides  allowing  correction  of  the  deformity, 
relieves  the  spasm.  But  when,  after  operating,  the  extremities  can 
be  held  in  position  for  use  without  undue  tension,  it  is  surprising 
how  much  more  good  is  apparently  accomplished  by  the  massage 
and  the  gymnastics.  Successful  use  of  the  muscles  often  stimulates 
the  child  mentally,  and  all  the  distressing  features  of  the  case  may 
be  alleviated  in  a  very  satisfactory  manner. 

The  tendo  Achillis  and  the  hamstring  tendons  are  those  most 
frequently  requiring  section.  These  may  be  divided  by  the  subcu- 
taneous or  open  methods.  When  the  fascia  also  requires  division 
in  the  popliteal  region  it  is  better  to  use  the  open  method,  closing 
the  skin  wound  afterward  with  sutures.  The  operations  and  the 
braces  are  exactly  the  same,  as  are  more  fully  described  in  sections 
on  tenotomies,  on  correction  of  deformities  in  poliomyelitis,  and  on 
correction  of  club-foot.  But  in  tenotomy  for  cerebral  paralysis  the 
deformity  is  merely  corrected, — not  over-corrected, — before  putting 
it  up  in  plaster.  After  the  plaster  bandages  are  dispensed  with,  a 
proper  brace  is  applied  and  used  for  months,  and  not  laid  aside  until 
there  is  no  tendency  to  relapse. 

In  epilepsy  following  trauma  if  the  lesion  can  be  localized,  opera- 
tion is  to  be  considered  ;  but  if  there  is  evidence  of  secondary  changes 
in  the  brain,  operation  would  probably  be  useless. 

OPERATIONS  UPON  NERVES 

Nerzfe  Transference  and  Suture  of  Nerves  in  the  Paralyses  of 
Childhood. — By  combining  the  studies  of  anatomists,  histologists, 
physiologists,  neurologists,  and  experimental  and  clinical  surgeons, 
an  immense  number  of  data  have  been  accumulated  concerning  the 
structure  and  functions  of  nerves  and  their  behavior  under  injury 
or  disease  and  under  operations.  Many  of  these  facts  are  applicable 
in  pediatric  surgery.  In  briefly  presenting  this  subject  I  shall  make 
use  of  the  excellent  monograph  of  Murphy  especially,  and  of  the 
papers  of  Harris  and  Low,  Kennedy,  Keen,  and  others,  without 
attempting  to  credit  each  observation  to  its  original  source. 

The  controversy  as  to  whether  a  peripheral  nerve  which  has 
been  a  long  time  severed   from  its  connection  with  the  cord,  or 


414  SURGICAL   DISEASES    OF   CHILDREN 

whose  ganglionic  cells  have  been  destroyed,  is  permanently  degen- 
erated, is  not  yet  quite  settled  in  the  minds  of  all.  But  it  is  held  by 
those  who  have  been  foremost  in  recent  studies  upon  the  subject, 
that  if  the  connection  between  the  severed  nerve  and  a  central  gan- 
glion is  properly  restored,  that  new  nerve  fibers  will  regenerate  even 
if  the  disconnection  had  been  long  continued  and  degenerative 
changes  had  taken  place.  The  new  fibers  will  not  be  anatomically  or 
physiologically  perfect  at  first,  but  under  the  stimulus  of  impulses 
from  the  center  they  will  develop  to  normal  structure  and  function. 
The  length  of  time  that  may  elapse  and  the  exact  degree  of  degen- 
erative change  that  may  make  such  restoration  impossible  have  not 
been  definitely  determined,  but  restoration  to  function  has  been  se- 
cured in  nerves  which  had  been  severed  many  years  before.  How- 
ever, the  sooner  the  severed  peripheral  segment  is  united  to  its  own 
proximal  segment  or  to  another  sound  nerve  the  sooner  and  the 
more  complete  will  be  the  functional  result.  All  nerves  provided 
with  a  neurilemma  are  capable  of  this  regeneration.  Nerves  with- 
out a  neurilemma,  the  aneurilemmic  axones,  are  incapable  of  re- 
generation. 

It  interests  pediatric  surgeons,  especially  in  connection  with  the 
subjects  of  peripheral  paralysis  and  poliomyelitis,  to  know  that  gan- 
glionic cells  and  aneurilemmic  axones  when  destroyed  never  re- 
generate ;  and  that  all  the  extra-spinal  nerves,  peripheral  nerves,  cra- 
nial and  spinal,  that  is,  all  peripheral  nerves  excepting  those  of  spe- 
cial sense,  are  medulated  and  neurilemmic,  and  are  therefore  capable 
of  regeneration  under  suitable  surgical  conditions. 

The  fundamental  principle  of  uniting  nerves  so  that  regenera- 
tion shall  take  place  and  function  be  secured  lies  in  the  fact  that 
the  peripheral  axones  in  the  nerves  are  insulated,  and  that  to  secure 
axonal  contact  the  axis-cylinders  should  be  brought  together  end 
to  end,  or  else  freed  from  their  insulation  if  joined  laterally. 

Nerve  transference  is  applicable  both  in  cases  of  peripheral 
paralysis  due  to  a  contusion  or  division  of  a  nerve  trunk,  resulting 
in  a  separation  of  the  divided  ends,  or  in  the  presence  of  scar  tissue 
which  will  not  transmit  impulses;  and  in  peripheral  degeneration 
due  to  destruction  of  the  ganglion  cells.  The  operative  treatment 
consists  in  the  re-establishment  of  the  continuity  of  the  divided  nerve 
or  the  anastomosis  of  the  peripheral  end  of  the  divided  nerve,  or  of 
the  nerve  whose  center  is  destroyed,  into  a  potent  nerve,  that  is,  one 
receiving  impulses  from  ganglionic  cells.  This  plan  of  treatment 
has  not  as  yet  been  carried  out  in  many  cases.  But  a  large  amount 
of  experimental  work  has  been  done,  and  tested  in  practice  suffi- 
ciently at  least  to  justify  Murphy's  statement  that  "  the  treatment  of 
the  various  palsies  by  nerve  anastomosis  is  destined  to  a  broader 


THE   PARALYSES    OF   INFANCY   AND   CHILDHOOD        415 

application,  we  firmly  believe,  as  the  principle  underlying-  this  treat- 
ment is  physiologically  and  histologically  established."^ 

In  all  operations  upon  nerve  trunks  an  important  step  is  the 
identification  of  the  nerve.  The  operator  should  not  depend  only 
upon  his  anatomical  knowledge,  for  the  tissues  at  the  seat  of  an  old 
injury  may  be  so  changed  in  structure  and  color  and  so  confused  in 
a  mass  of  connective  tissue  as  to  be  unrecognizable.     To  meet  this 


Fig.  143.    Diagrams  i  to  8  showing  various  methods  of  nerve  suture. 

difficulty  a  nerve  excitor  is  used.  This  consists  in  a  metallic  electrode 
having  at  one  end  two  platinum  needles  or  tips  three  centimetres 
long,  with  their  points  five  millimetres  apart.  At  the  other  end  the 
needles  are  connected  with  a  faradic  battery  having  a  weak  current. 
The  metallic  handle  and  needles  are  sterilized  and  can  be  used  by  the 
operator  during  his  dissection.  Upon  touching  a  motor  nerve  with 
the  needles,  the  muscles  in  its  area  of  distribution  contract,  and  many 
mistakes  are  thus  avoided. 

1  Magazine  of  Surg.,  Gynec,  and  Obstet.,  April,  1907. 


4i6  SURGICAL    DISEASES    OF    CHILDREN 

Nerve  suture  may  be  primary,  that  is,  within  twenty-four  hours 
after  division ;  or  secondary,  when  months  or  years  have  intervened 
between  the  injury  and  the  attempt  at  restoration.  In  secondary 
suture  connective  tissue  should  be  removed  from  nerve  endings  that 
are  to  be  joined.  Axis  cyHnders  or  nerve  fibers  will  extend  their 
growth  a  considerable  distance  under  favorable  circumstances,  but 
they  cannot  penetrate  cicatricial  tissue.  If  the  nerve  ends  can  be 
brought  to  face  each  other  with  only  slight  traction,  they  are  easily 
sutured  in  position.  Even  a  little  stretching  is  permissible.  Fig. 
143,  Diagrams  i  to  8,  show  different  methods  of  joining  the  nerves. 

The  needle  should  be  a  round  intestinal  needle  and  the  suture 
fine  silk,  or  chromicized  catgut,  linen,  or  kangaroo  tendon.  The 
suture  should  be  passed  through  the  perineurium  and  through  the 
surrounding  connective  tissue,  and  (this  is  an  important  point) 
not  through  the  nerve  itself.  If  there  is  a  considerable  gap  between 
the  two  ends,  a  flap  method  is  resorted  to ;  or  a  segment  of  nerve  or 
of  spinal  cord,  or  a  piece  of  artery  from  small  animals,  or  a  bundle 
of  catgut,  or  a  tube  of  a  decalcified  bone,  is  interposed  to  fill  the  gap 
and  afford  a  bridgework  for  the  construction  of  the  new  nerve 
tissue.  Sometimes  the  peripheral  end  of  the  severed  nerve  is  united 
to  the  side  of  a  sound  nerve,  or  to  a  portion  of  it  detached  for  that 
purpose.  In  order  to  prevent  the  encroachment  of  new  connective 
tissue  at  the  seat  of  union,  various  procedures  are  resorted  to.  Ster- 
ilized tubes  of  decalcified  bone,  of  gelatine,  of  magnesium,  of  the 
arteries  of  animals,  Cargile  membrane,  membrane  lining  an  egg- 
shell, wax  or  parafiine  are  used.  When  available  at  the.  seat  of 
operation  the  fascia,  or  muscle  or  fatty  tissue  adjacent  should  be 
drawn  around  the  point  of  suture  as  a  protection.  Primary  union  is 
absolutely  necessary  for  success.  If  union  takes  place,  restoration 
of  function  comes  in  a  certain  order,  first  trophic,  then  sensory,  an,d 
finally  motor.  The  time  necessary  for  restoration  of  function  varies 
much  in  different  cases,  and  as  yet  no  definite  knowledge  has  accu- 
mulated ;  but,  approximately,  sensation  does  not  return  sooner  than 
six  weeks  nor  motion  sooner  than  twelve  weeks.  (32) 


CHAPTER  XVI 

THE  SPINE 

Malformation  of  the  Sacrum — The  Normal  Curves  of  the 
Spine — Lateral  Curvature  or  Rotary-Lateral  Curva- 
ture (Scoliosis) — Tuberculosis  of  the  Spine  (Pott's 
Disease;  Caries  of  the  Spine;  Spondylitis). 

The  conditions  o£  the  spine  with  which  the  children's  surgeon 
should  be  acquainted  are  the  malformations,  tumors,  curvatures, 
including  the  rickety  deformities,  spondylitis,  Pott's  disease  or  caries, 
the  typhoid  spine,  the  hysterical  spine  and  cases  of  injury. 

Sarcoma  of  the  spine,  aneurism  of  the  abdominal  aorta,  syphilis, 
actinomycosis,  and  hydatids  of  the  spine,  are  infrequent  or  so  ex- 
tremely rare  as  only  to  be  mentioned  as  possible. 

SPINA   BIFIDA 

The  nerve  elements  of  the  spinal  cord  are  derived  from  the 
epiblast.  At  first  a  mere  furrow  forms  in  the  outer  layer  of  the 
blastoderm.  The  furrow  deepens  into  a  groove,  and  by  the  closing 
of  the  margins  of  this  groove  a  tube  is  formed — the  neural  canal. 
The  mesoblast  furnishes  serous  and  fibrous  elements  which  take 
their  places  around  the  neural  canal.  And  from  the  mesoblast  also 
are  derived  masses  of  cells  at  each  side  of  the  canal.  These  cells  are 
destined  to  form  the  vertebrae.  They  extend  around  in  front  and 
form  the  vertebral  bodies,  and  they  also  extend  backward,  forming 
the  medullary  or  dorsal  plates ;  and  they  arch  over  the  neural  canal, 
enclosing  it  in  what  will  become  the  vertebral  canal  with  its  column 
of  bodies,  and  arches  and  spinous  processes.  But  if  the  dorsal  plates 
fail  to  meet  and  close  at  a  certain  point,  there  will  be  a  lack  of 
vertebral  arches  and  spinous  processes,  and  through  this  cleft 
the  spinal  meninges,  or  the  cord  with  the  meninges  will  protrude 
posteriorly.  There  may  be  a  failure  of  formation  in  one  or  more 
vertebral  bodies  and  allow  protrusion  of  the  canal  contents  ante- 
riorly. Or  it  may  protrude  through  one  of  the  foramina.  Such 
protrusions,  whether  anterior,  or,  as  is  far  more  frequently  the  case, 
posterior,  constitute  spina  bifida,  (See  Figs.  144  and  145.)  This 
peculiar  pathological  condition  is  usually  classed  with  the  mal- 
formations, and  yet  it  often  bears  a  relationship  to  the  tumors. 
Its  surgery  is  closely  associated  with  that  of  the  spinal  cord  and 
nerves.    It  could  also  be  well  classed  with  cranial  meningocele  and 

417 


4i8 


SURGICAL   DISEASES    OF   CHILDREN 


encephalocele ;  and  it  often  enters  into  a  discussion  of  syringo- 
myelia and  of  hydrocephalus.  Spina  bifida  is  always  congenital, 
never  acquired.  It  is  either  "  true  "  or  "  false."  True  spina  bifida 
consists  in  a  protrusion  of  the  spinal  meninges  or  elements  of  the 
spinal  cord,  or  both,  through  an  opening  in  the  spinal  canal,  making 


Figs.  144  and  145.  Spina  bifida.  This  child  was  one  of  a  family  of  twelve 
children,  three  of  whom  had  a  malformation.  Its  mother  had  nine  chil- 
dren by  first  husband.  The  second  child  had  webbed  toes  on  the  left 
foot.  By  the  second  husband  there  were  three  children,  the  first  of 
whom  had  its  mouth  one  inch  too  wide  on  the  left  side.  This  babe  is 
the  third. 

a  soft  tumor  external  to  the  canal.  Whether  an  abnormal  increase 
of  the  fluid  in  the  spinal  canal  has  led  to  this  hernia  of  the  meninges 
and  prevented  a  closure  of  the  vertebral  canal,  or  whether  the  failure 
of  the  vertebral  canal  to  close  is  primary,  are  yet  unsettled  points. 
Certain  it  is  that  true  spina  bifida  is  sometimes  associated  with  hy- 
drocephalus and  with  cranial  meningocele,  or  encephalocele.  It  is 
also  true  that  it  occurs  occasionally  in  connection  with  hiatus  of  the 
bladder,  a  developmental  failure,  and  that  it  is  associated  with  con- 
genital tumors  of  the  spinal   canal,   such   as  lipomata,  fibromata, 


THE    SPINE  419 

angiomata,  chondromata,  sarco-coccygeal  cysts,  and  teratomata. 
Other  pathological  conditions  accompany  spina  bifida,  such  as  club- 
foot, paralysis  of  the  lower  extremities  and  of  the  bladder  and 
rectum,  doubtless  resulting  from  the  involvement  of  the  cord  at  the 
seat  of  the  tumor.  Children  with  spina  bifida  are  often  but  not  al- 
ways defective  mentally.  The  condition  is  also  frequently  accom- 
panied by  general  feebleness  and  poor  nutrition. 

The  tumor  is  in  or  near  the  median  line,  most  commonly  pro- 
jecting posteriorly  in  the  lumbo-sacral  region  (where  the  canal 
normally  is  last  to  close),  but  may  be  in  the  sacral,  high  lumbar, 
dorsal  or  even  in  the  cervical  regions.  (See  also  Chapter  on 
Tumors.) 

The  tumor  may  be  red,  translucent,  or  oozing  the  contained 
fluid ;  or  partly  covered  with  skin,  the  skin  becoming  thinner  and 
thinner  toward  the  center  of  the  protrusion,  leaving  only  the  mem- 
branous arachnoid.  In  the  usual  type  of  spina  bifida  the  size  of  the 
protrusion  may  cover  an  inch  or  two,  or  rarely  be  as  large  as  the 
child's  head.  It  may  become  distended  when  the  child  cries,  or  in 
an  infant  the  fontanelle  may  be  distended  by  pressing  upon  the 
tumor.  It  may  be  constantly  distended  as  if  about  to  burst  or  be 
quite  compressible,  or  wrinkled  or  shrunken.  Sometimes  the  bony 
margins  of  the  opening  in  the  vertebral  canal  can  be  felt.  This 
opening  may  involve  only  one  or  two  or  several  vertebral  arches. 
In  extremely  rare  instances  all  the  vertebral  arches  from  the  cervical 
to  the  sacral  regions  may  be  lacking.  This  is  called  rachischisis 
totalis.  The  tumor  may  have  burst  at  the  birth,  or  have  ulcerated 
through.  Where  there  is  tumor  growth  in  connection  with  spina 
bifida  more  solid  tissues  will  be  felt  in  the  walls  of  the  sac  and 
there  may  be  a  hairy  growth  upon  the  skin  of  the  covering. 

True  spina  bifida  may  be  divided  into  three  varieties :  First, 
spinal  meningocele  which  consists  merely  in  a  protrusion  of  the 
membranes  of  the  cord  containing  cerebro-spinal  fluid.  It  corre- 
sponds to  the  meningocele  occurring  upon  the  cranium.  The  lining 
of  the  sac  is  the  arachnoid,  and  the  outer  coverings  vary  in  their 
representation  in  different  cases.  The  tumor  is  apt  to  be  translu- 
cent, in  the  middle  line,  and  higher  in  the  spine  than  the  majority 
of  spina  bifida,  and  may  protrude  through  a  comparatively  small 
opening  in  the  spinal  canal. 

The  second  variety  is  meningomyelocele,  so  named  because 
it  contains,  besides  the  meninges,  some  elements  of  the  spinal 
cord.  In  the  fetus  at  the  fourth  month  the  cord  occupies  the  entire 
vertebral  canal.  But  from  that  time  on  the  canal  exceeds  the  cord 
in  its  rate  of  growth,  so  that  at  birth  it  terminates  at  the  level  of  the 
first  lumbar  vertebra  in  the  cauda-equina  and  filum  terminale 
which  occupy  the  remainder  of  the  spinal  canal.     If,  then,  the  cord 


420  SURGICAL  DISEASES    OF   CHILDREN 

itself  has  not  suffered  too  seriously  in  its  development,  some  por- 
tion of  it  or  its  terminal  elements  may  sometimes  be  seen  by  the  aid 
of  properly  transmitted  light,  fused  with  the  membranous  cover- 
ing of  the  meningomyelocele  or  drawing  it  into  folds.  These  cases 
of  implication  of  the  cord  or  cauda-equina  are  apt  to  be  associated 
with  clubbed-feet  or  paralytic  lower  extremities  and  defecti\e  in- 
nervation of  the  pelvic  viscera.  The  vertebral  defect  is  apt  to  be 
large  and  the  tumor  wide  at  its  base. 

The  third  variety,  called  syringomyelocele,  has  the  dilatation 
producing  the  tumor  in  the  central  canal  of  the  cord.  It  does  not 
produce  great  distension,  so  that  the  covering  is  not  thinned,  often 
appearing  quite  like  normal  skin.  Being  often  a  small  tumor  and 
not  always  quite  in  the  median  line,  it  is  apt  to  be  mistaken  for 
spina  bifida  occulta,  or  one  of  the  other  congenital  tumors. 

Spina  bifida  occulta,  or  false  spina  bifida,  resembles  spina 
bifida  in  its  location  and  also  in  that  it  does  come  from  within 
the  spinal  canal  through  a  defect  in  its  bony  arches ;  but  it  has  no 
cavity  containing  cerebro-spinal  fluid,  and  is  said  to  contain  none 
of  the  constituents  of  the  spinal  cord.  In  those  cases  presenting 
some  degree  of  anesthesia  and  perforating  ulcers,  doubtless  the 
cord  is  implicated,  whether  within  the  canal  or  outside  in  the  pro- 
jecting tumor  it  may  be  impossible  to  determine.  It  may  have  been 
a  true  spina  bifida  which  underwent  spontaneous  cure. 

Differential  Diagnosis. — The  possibility  of  anterior  spina  bifida 
should  not  be  forgotten  when  examining  for  abdominal  and  pelvic 
tumors.  Several  cases  have  been  reported  in  children  and  in  adults 
in  which  anterior  spina  bifida  was  discovered — sometimes  after  it 
had  been  dealt  with  upon  a  mistaken  diagnosis.  The  presence  of 
club-feet  or  paralysis  of  lower  extremities  with  an  obscure  abdom- 
inal enlargement  would  arouse  suspicion  at  once.  But  diagnosis 
might  be  impossible  in  many  cases  without  an  exploratory  lapa- 
rotomy. It  will  not  do  to  pronounce  every  external  congenital  tume- 
faction along  the  spine  a  spina  bifida.  It  should  be  differentiated 
from  the  congenital  sacral  tumors,  from  dermoids,  teratomata, 
lipomata,  lymphangiomata,  fibromata  and  tumors  compounded  of 
more  than  one  of  these  varieties.  (See  chapter  on  Tumors.)  Also 
an  attempt  should  be  made  by  careful  examination  to  distinguish 
which  variety  of  spina  bifida  is  presented,  as  this  influences  the 
prognosis  and  the  treatment. 

Prognosis. — The  prognosis  in  most  cases  is  unfavorable  and 
in  all  doubtful.  Infection  of  the  sac  may  extend  to  its  interior 
and  result  in  meningitis,  myelitis,  destruction  of  the  cord,  and  death. 
(See  Fig.  146.)  Or  pressure  or  irritation  of  the  sac  may  set  up 
ulceration,  and  the  sac  opening  and  fluid  escaping,  convulsions  and 
death  rapidly  follow. 


THE    SPINE  421 

The  smaller  the  defect  in  the  spinal  arches,  the  smaller  the 
tumor,  the  thicker  and  more  natural  its  coverings,  the  less  the  other 
deformities  or  paralyses,  the  better  are  the  prospects  of  either  a 
spontaneous  obliteration,  which  sometimes  occurs,  or  of  a  successful 
operation.  The  meningomyelocele,  with  its  extensive  base  connect- 
ing through  a  large  opening  with  the  interior  of  the  spinal  canal ; 
with  its  thin  membranous  covering  in  which  are  involved  portions 
of  the  cord,  compels  a  very  doubtful  prognosis.  The  meningocele, 
even  if  it  be  rather  large,  having  its  communication  with  the  spinal 
canal  small  and  easily  shut  off,  and  skin  flaps  obtainable,  offers  a 


Fig.  146.  Spina  bifida.  Infection  occurred  through  the  ulcerating  mem- 
branous covering  of  the  spinal  meningocele,  and  the  infant  died  of 
meningitis. 

fair  chance  for  operative  success,  if  hydrocephalus  does  not  interfere 
with  ultimate  recovery. 

The  syringomyelocele,  which  is  apt  to  be  small  and  well  cov- 
ered in,  is  a  rather  hopeful  case  as  to  life;  although  neither  in  this 
nor  in  meningomyelocele  can  improvement  in  sensory  or  motor 
defects  of  the  parts  below  the  cord  lesion  be  expected.  Cases 
ulcerating  or  inflamed  at  birth  or  when  first  seen  are  likely  to  die 
of  meningitis  in  a  few  days.  Cases  of  spontaneous  cure  by  cica- 
trization after  emptying  of  the  sac  by  oozing,  have  been  reported, 
but  this  result  is  not  to  be  expected. 

Treatment. — Several  methods  of  treatment  are  open  to  the 
choice  of  the  surgeon,  and  these  have  been  variously  modified. 
First,  the  spina  bifida  may  simply  be  protected  from  pressure  and 
irritation.  This  may  be  done  by  means  of  a  cup-shaped  appliance 
made  of  sole  leather  or  metal  with  round  edge,  or  a  wire  frame  with 
its  edge  covered  by  India  rubber  tubing  or  otherwise  rounded,  or 
similar  contrivance.  The  cup  should  not  press  upon  the  tumor  at 
any  part  and  should  rest  upon  sound  skin.  To  simply  pile  a  few 
layers  of  gauze  and  cotton  upon  a  spina  bifida,  as  one  sometimes 
sees  done,  is  no  protection  from  pressure,  but  the  reverse.     The 


422  SURGICAL   DISEASES    OF   CHILDREN 

surface,  if  moist,  should  be  dusted  antiseptically.  This  treatment 
is  appHcable  to  small  tumors  in  which  spontaneous  obliteration  may- 
be hoped  for,  or  cases  in  which  immediate  consent  to  operation 
cannot  be  obtained,  or  may  be  of  doubtful  utility. 

Secondly,  the  injection  method,  or  Morton's  method.  Morton 
used  a  preparation  of  ten  grains  of  iodine  and  thirty  grains  of 
iodide  of  potassium  in  an  ounce  of  glycerine.  With  the  child 
lying  upon  its  side,  and  under  antiseptic  precautions,  a  fine  aspirat- 
ing needle  is  made  to  enter  the  cavity  through  healthy  skin  at  a  little 
distance  to  one  side  of  the  tumor,  and  a  part  of  its  contents  allowed 
to  escape,  in  quantity  according  to  the  amount  of  tension.  But  it  is 
not  desired  to  collapse  the  sac  completely.  Then  about  a  drachm 
of  the  glycerine  mixture  is  injected  through  the  needle,  while  the 
opening  into  the  spinal  canal  is  shut  off  from  the  sac  if  possible. 
The  needle  is  withdrawn  and  the  puncture  sealed  with  collodion. 
A  protective  dressing  is  applied  and  the  child  kept  lying  upon  its 
side  for  a  few  hours.  The  glycerine  being  heavy,  does  not  rapidly 
mix  with  the  cerebro-spinal  fluid  in  the  spinal  canal,  but  remains 
for  the  most  part  in  the  sac  and  excites  alteration  in  its  tissues. 
The  injection  is  generally  repeated  at  intervals  of  a  week  or  a 
week  and  a  half.  Morton  advised  that  this  method  be  begun  when 
the  infant  is  from  three  to  six  weeks  old. 

A  third  method  is  radical  operation  by  removal  of  the  sac  or  a 
portion  of  it  and  closing  the  meningeal  and  cutaneous  flaps  sepa- 
rately by  careful  suturing.  A  muscular  cutaneous  flap  may  be 
utilized  to  fill  the  hiatus.  (Bayer.)  A  further  elaboration  of  the 
radical  plan  is  a  closure  or  partial  closure  of  the  vertebral  opening 
by  chiseling  an  osteo-plastic  flap  from  the  rudimentary  laminae 
on  each  side.     (Selenko-Boborof.) 

The  vertebrse  (excepting  the  atlas  and  axis)  have  each  three 
centers  of  ossification,  one  for  the  body  and  one  for  each  of  the 
laminae  which,  uniting  posteriorly,  form  the  arch  and  extend  into 
the  spinous  process.  At  birth  the  ossification  of  the  laminae  gen- 
erally has  not  united  them  posteriorly,  although  Ballantyne 
found  them  united  in  several  specimens.  The  formation  of  the 
arches  and  their  ossification  takes  place  last  in  the  lumbar  or 
lumbo-sacral  region.  In  cases  of  spina  bifida  there  is  no  uni- 
formity in  the  degree  of  the  hiatus  in  the  spinal  canal,  and  there 
may  be  rudimentary  arches  which  have  made  an  attempt  at  ossifi- 
cation, and  being  divided  at  their  base  laterally  are  brought  to  the 
middle  line  and  sutured  together.  Portions  of  the  sacrum  chiseled 
off,  but  still  retaining  their  muscular  attachment,  have  been  used 
in  the  flap  formation. 

Radical  operation  promises  best  in  those  cases  in  which  the 
opening  into  the  spinal  canal  is  small,  or  in  which  if  it  is  larger  there 


THE    SPINE  423 

are  adequate  skin  flaps  available.  If  nerves  be  found  fused  with 
the  membranous  covering  of  the  tumor,  perhaps  portions  of  the 
sac  between  the  nerve  strands  may  be  sacrificed,  and  the  remainder, 
after  suturing,  be  folded  in  to  fill  the  cavity  in  the  canal,  and 
covered  with  the  skin  flaps. 

The  nerve  strands  are  apt  to  be  connected  with  the  middle 
portion  of  the  posterior  wall  of  the  tumor.  In  this  case  the  dissec- 
tion is  best  begun  at  the  side.  If  pedunculated  the  sac  may  be  iso- 
lated and  temporarily  compressed  while  it  is  opened  and  examined. 
If  free  from  nerve  structures  it  may  be  ligated  at  its  base.  If  it 
contain  the  expanded  cord  itself  the  latter  should  be  replaced  within 
the  canal  and  retained  by  closing  the  sac  with  sutures.  If  the  sac 
contain  the  nerves  of  the  cauda  the  atrophied  portions  should  be 
excised  and  the  severed  ends  united  end  to  end.  (Murphy.)  The 
cauda-equina,  although  within  the  dura,  is  a  collection  of  extra- 
medullary  spinal  axones  with  a  medullary  sheath  and  neurilemma, 
and  capable  of  regeneration  the  same  as  the  axones  of  peripheral 
nerves.  (See  Section  on  Nerve  Transference  and  Suture  of 
Nerves.)  Careful  suturing  of  the  flaps  is  necessary.  The  meninges 
should  be  sutured  with  fine  chromicized  catgut  or  kangaroo  tendon 
in  continuous  suture ;  and  the  skin  with  silkworm  gut.  The  menin- 
ges and  skin  are  best  not  united  in  the  same  line.  Immediate 
union  is  sought  and  may  be  obtained,  but  meningitis  is  liable  to 
ensue  upon  any  operative  procedure  upon  spina  bifida,  unless  the 
most  rigid  aseptic  technique  is  carried  out. 

MALFORMATION  OF  THE  SACRUM 

In  the  infant  and  young  child  the  sacrum  and  coccyx  are  more 
in  direct  line  with  the  rest  of  the  vertebral  column,  and  present 
less  concavity  on  the  pelvic  surface  than  in  the  adult.  However, 
there  is  at  birth  normally  an  anterior  sacro-coccygeal  concavity, 
extending  from  the  promontory  of  the  sacrum  to  the  tip  of  the 
cartilaginous  coccyx.  In  some  cases  the  infantile  straightness  of 
the  sacrum  and  coccyx  is  exaggerated,  and  there  appears  externally 
in  the  region  of  the  coccyx  a  so-called  "  post-anal  dimple."  These 
cases  may  have  the  line  of  the  sacrum  extended  farther  backward 
than  normal  from  the  line  of  the  lumbar  spine. 

THE    NORMAL    CURVES    OF   THE    SPINE 

Early  in  the  development  of  the  fetus  the  spinal  column  has  but 
one  curve,  its  concavity  forward.  Later  the  promontory  of  the 
sacrum  appears  and  divides  this  into  two,  a  shorter  curve  below 
and  a  longer  above,  each  concave  anteriorly.  At  birth  there  still 
persists  a  tendency  to  anterior  concavity  in  the  dorsal  spine.  But 
for  practical  purposes  it  may  be  stated  that  the  normal  infant's 


424  SURGICAL   DISEASES    OF   CHILDREN 

spine,  with  the  exception  of  the  projection  of  the  promontory  of 
the  sacrum,  is  straight,  up  to  the  time  that  he  assumes  the  upright 
position.  At  any  rate  it  has  no  curves  which  are  made  constant 
either  by  bony  or  cartilaginous  formation,  by  the  binding  of  Hga- 
ments  or  the  tension  of  muscles,  but  is  a  perfectly  flexible  column 
which  will  change  its  curves  according  to  the  position  in  which  the 
infant  is  placed.^  But  as  the  infant  begins  to  hold  its  head,  and 
later  its  body  in  the  upright  position,  the  cervical  and  then  the 
dorsal  curves  are  formed.  Still  later,  when  standing  and  walking 
are  essayed,  and  the  spine  and  pelvis  with  the  body  on  the  anterior 
side  of  its  center  of  gravity  must  be  balanced  upright  upon  the 
femurs,  the  action  and  counter  action  between  weight  and  muscular 
tension  produce  the  lumbar  curve.  The  sacrum  retains  its  anterior 
concavity,  and  even  increases  it  in  the  course  of  the  development  of 
the  pelvis  and  pelvic  contents.  When  normal  growth  is  attained 
the  cervical  and  lumbar  portions  of  the  spine  have  their  convexity 
anteriorly.  In  the  dorsal  spine  the  main  curve  has  its  convexity 
posteriorly.  Some  anatomists  describe  also  as  normal  a  very  slight 
lateral  curve  of  the  whole  length  of  the  dorsal  region  with  its  con- 
vexity to  the  right.  These  curves,  when  not  exaggerated,  do  not 
appreciably  diminish  the  weight-supporting  strength  of  the  spine, 
while  they  greatly  increase  its  flexibility,  and  especially  add  to  its 
elasticity,  relieving  the  spinal  cord  and  brain  of  the  shock  of  con- 
cussion. As  stated,  in  the  infant  the  normal  curves  can  be  oblit- 
erated by  laying  it  on  its  back  upon  a  plane  surface ;  but  gradually, 
as  age  and  development  advance,  they  become  more  fixed  in  the 
dorsal  and  lumbar  regions,  although  in  the  latter  the  consolidation 
of  the  curve  does  not  take  place  till  adult  life.  According  to  Sym- 
ington's observations,  the  cervical  curve  is  never  consolidated,  but 
can  even  in  the  adult  be  obliterated  by  strong  flexion  of  the  head 
upon  the  thorax.  This  is  doubtless  true.  It  is  within  the  observa- 
tion of  all  that  the  degrCiC  of  the  normal  curves  as  well  as  the  flexi- 
bility of  the  vertebral  column  vary  considerably  in  different  indi- 
viduals of  the  same  age  and  can  be  varied  greatly  at  will  by  practice. 
Flexibility  diminishes  and  the  curves  become  more  fixed  with  age 
and  development,  the  advance  of  ossification  of  the  bony  skeleton, 
and  increased  density  of  cartilage,  ligament  and  muscle. 

LATERAL  CURVATURE  OR  ROTARY-LATERAL  CURVATURE 

(SCOLIOSIS) 

This  variety  of  abnormal  curvature  of  the  spine  is  not  due  to 
any  disease  of  the  spine  itself,  but  there  may  be  congenital  mal- 
formation of  the  bodies  of  the  vertebrae,  producing  a  curve.  It 
may  be  due  to  general  weakness  of  the  muscles  which  should  hold 

1  Ballantyne's  Introduction  to  the  Diseases  of  Infancy. 


THE    SPINE  425 

the  spine  in  its  normal  position.  The  weakness  may  be  but  one 
manifestation  of  the  general  enfeeblement  of  rickets,  or  that  fol- 
lowing a  fever  or  other  severe  illness,  or  that  which  accompanies 
too  rapid  growth  in  height  without  corresponding  increase  in 
strength  and  stamina,  often  combined  with  habitual  faulty  attitude. 
Scoliosis  may  be  due  to  muscular  weakness  from  paralysis,  for 
instance  hemiplegia  or  poliomyelitis.  It  may  be  compensatory  to 
some  inequality  in  the  length  of  the  lower  extremities,  such  as  a  con- 


FiG.  147.  Spinal  curvature  from  pseudo-hypertrophic  paralysis.  Same 
case  as  Fig.  2)7  taken  two  years  later.  Note  the  atrophy  of  the  muscles 
of  the  shoulders  and  trunk. 

genital  shortness  of  one  limb,  or  to  a  fracture  with  shortening,  or 
joint  disease  of  hip,  knee  or  ankle,  or  congenital  hip  dislocation 
unilateral,  or  to  flat-foot.  Scoliosis  may  be  caused  by  atelectasis 
pulmonum,  or  empyema,  with  or  without  thoracoplasty,  or  to 
pseudo-hypertrophic  muscular  paralysis,  as  in  Fig.  147.  It  is  occa- 
sionally produced  by  tuberculosis  of  the  spine,  afifecting  one  side 
only  of  the  vertebral  body,  or  by  torticollis  or  cicatrices.  Scoliosis 
is  sometimes  said  to  belong  to  the  period  of  young  adult  life,  but  it 


426 


SURGICAL  DISEASES    OF   CHILDREN 


may  occur  in  infancy  and  is  common  enough  in  childhood  and  fre- 
quent in  youth  approaching  puberty.  Those  cases  due  to  malfor- 
mation of  the  spinal  column  itself  are  of  course  manifest  early  in 
life;  hkewise  those  due  to  congenital  shortening  of  one  limb.  The 
rickety  cases  make  their  appearance  in  infancy  and  early  childhood, 

(see  Figs.  24  and  148), 
and  those  due  to  paraly- 
sis are  also  apt  to  ap- 
pear in  childhood.  Those 
from  empyema  in  child- 
hood or  youth.  (See 
Fig.  189.)  These  forms 
of  course  continue  into 
the  subsequent  periods, 
while  youth,  puberty 
and  adolescence  are  es- 
pecially productive  of 
the  very  common  class 
of  cases  due  to  general 
feebleness,  muscular  and 
ligamentous  relaxation 
with  habitual  faulty  at- 
titudes. 

The  principles  in- 
volved in  the  produc- 
tion of  scoliosis  are  the 
same  in  all  cases,  al- 
though the  initiation  of 
the  trouble  varies  ac- 
cording to  the  cause. 
For  example,  if  the 
left  lower  extremity  is 
shorter  than  the  right, 
as  in  congenital  malfor- 
mation, or  from  injury 
or  disease,  the  left  side 
of  the  pelvis  will  drop 
to  a  lower  level  and  the  lumbar  spine  must  make  a  primary  curve 
to  the  right  to  maintain  the  equilibrium.  The  body  thus  lean- 
ing toward  the  right,  if  the  shoulders  and  head  are  to  be  held 
upright  the  dorsal  spine  must  make  a  secondary  curve  to  the 
left. 

In  the  case  of  general  muscular  feebleness  suppose  the  child 
sit  on  a  level  seat  with  the  right  side  toward  a  desk,  the  right 
elbow  resting  upon  the  desk  and  raising  the  right  shoulder,  while 


Fig.  148.  Rachitic  spine.  Rickety  curva- 
ture of  the  spine  is  usually  simply  a 
convex  bowing;  but  this  shows  there 
may  be  also  a  lateral  curvature.  This 
habitual  position  of  sitting  bearing 
weight  upon  arm  has  also  bowed  the 
left   forearm   in   the   same   curve. 


THE   SPINE  427 

the  left  elbow  hangs  at  its  side.  Here  the  dorsal  spine  describes 
a  primary  lateral  curve  with  its  convexity  to  the  right,  while  the 
lumbar  spine  must  make  a  secondary  or  compensatory  curve,  with 
its  convexity  to  the  left.  The  thorax  overhangs  the  pelvis  on  the 
right  side,  while  the  right  lower  ribs  approach  the  iliac  crest.  On 
the  left  side  the  hip  bone  projects  far  outward  from  its  normal  line 
and  its  crest  is  separated  widely  from  the  lower  ribs.  The  muscles 
project  in  a  ridge  along  the  convex  sides  of  the  curvature.  A 
primary  dorsal  curvature  convex  to  the  right  is  the  variety  most 
frequently  met,  but  a  curvature  to  either  left  or  right  may  take 
place  in  any  region  of  the  spine,  and  may  have  its  compensatory 
curvature  in  other  regions.  If  there  is  a  secondary  curve  it  is 
of  course  in  the  direction  opposite  from  the  primary,  and  if  there 
are  three  they  alternate  in  direction. 

These  lateral  curvatures  are  not  simple  inclinations  of  the 
spine  to  one  or  the  other  side,  but  involve  a  rotary  deviation  or 
twist  in  the  column  of  vertebrae,  those  vertebrae  involved  in  the 
curvature  turning  their  bodies  to  face  its  convex  side.  This  rota- 
tion of  the  vertebrae  upon  a  vertical  axis,  of  course,  causes  the  trans- 
verse processes  to  point  farther  backward  and  to  separate  on  the 
convex  side  of  the  curve,  while  on  the  concave  side  they  point 
farther  forward  and  are  crowded  together.  In  the  dorsal  curva- 
ture the  ribs  necessarily  follow  the  same  course,  in  time  producing 
deformity  of  the  thorax,  which  shows  a  projection  and  has  its 
cavity  increased  upon  the  convex  side,  while  it  recedes  and  has  a 
lessened  capacity  on  the  side  of  the  concavity  of  the  spinal  curva- 
ture. (See  Figs.  149  and  150.)  The  scapula  upon  the  convex 
side  cannot  lie  flat  upon  such  a  rounding  surface,  but  its  lower  angle 
projects  backward  and  outward.  On  the  concave  side  the  scapula 
is  on  a  lower  level  than  its  fellow  and  its  angle  approaches  the  spine. 
The  vertical  length  of  the  body  is  shortened. 

In  the  early  stages  of  scoliosis,  excepting  in  congenital  mal- 
formation, the  curvature  can  be  corrected  by  changing  the  position, 
shifting  or  removing  the  superimposed  weight.  But  if  a  faulty 
position  be  habitually  maintained  for  a  considerable  length  of 
time,  and  the  muscles  be  too  weak  or  inactive  to  correct  it  entirely 
in  the  intervals,  the  overstretched  ligaments  become  lengthened, 
cartilage,  and  even  bone,  by  compression  upon  one  side  greater  than 
upon  the  other,  grow  correspondingly  misshapen,  and  the  deform- 
ity at  first  temporarily  permitted  by  the  muscles  is  permanently 
fixed  in  the  bony  skeleton,  in  its  cartilaginous  cushions  and  its 
fibrous  supports.  (33) 

More  than  one  cause  may  take  part  in  the  formation  of  a  cur- 
vature. For  example,  an  infant  with  torticollis  may  become  rickety, 
or  a  rickety  child  be  paralyzed.     The  s^m§  cause  may  act  both 


428 


SURGICAL   DISEASES    OF   CHILDREN 


directly  and  indirectly ;  for  example,  a  bowed  leg  from  rickets  may 
tilt  the  pelvis  in  conjunction  with  a  rickety  spine  and  produce  a 


B'$ 


Fig.  149.  Right  dorsal 
rotary-lateral  curvature. 
The  dark  line  shows  the 
position  of  the  spinous  pro- 
cesses, demonstrating  that 
the  rotation  is  greater  than 
the  curvature  would  seem 
to   indicate. 


Fig.  150.  Same  case  as 
Fig.  149,  showing  thoracic 
deformity  from  spinal  cur- 
vature in  an  otherwise  well- 
formed  girl  of  13  years. 
Chest  capacity  increased  on 
convex  side;  decreased  by 
compression  on  concave 
side. 


lateral    curvature.      Or    a    lateral    tubercular    spondylitis    may   be 
coexistent  with  morbus  coxae  and  a  shortened  limb. 


THE   SPINE  429 

Scoliosis  is  very  unequally  divided  between  the  sexes,  a  very 
large  share  going  to  the  girls.  This  is  explained  by  their  inferior 
physical  vigor,  and  their  customary  indoor  and  sedentary  occupa- 
tions. 

Rickets  is  apt  to  produce  a  general  bowing  of  the  whole  spine 
with  the  convexity  backwards.  This  kyphosis,  as  it  is  called,  even 
if  it  involve  less  than  the  entire  spine,  is  larger  and  rounder  than  the 
angular  curvature  or  kyphosis  of  spinal  caries.  Rickets  may  also 
less  frequently  produce  a  lateral  curvature  of  the  spine,  as  shown 
in  Fig.  148. 

Lordosis  is  a  concavity  posteriorly  in  the  lumbar  or  cervical 
regions.  In  the  lumbar  region  it  may  result  from  congenital  dis- 
location of  the  hip,  or  morbus  coxge,  or  accompany  a  kyphosis  from 
Pott's  disease  of  the  dorsal  spine,  or  be  due  to  paralysis  of  the  mus- 
cles of  the  back,  or  to  carrying  too  heavy  a  weight  in  front  of  the 
body.  It  may  be  alone  or  more  frequently  combined  with  lateral 
curvature ;  occasionaly  it  accompanies  congenitally  an  abnormally 
straight  sacrum  which  projects  downward  and  backward  from 
the  sacro-lumbar  joint.  Lordosis  in  the  cervical  region  is  occa- 
sionally seen  in  feeble  children  compensatory  to  a  rickety  kyphosis 
of  the  dorsal  region.  (34) 

Examination  and  Diagnosis. — The  case  may  come  to  the  sur- 
geon with  the  diagnosis  of  spinal  curvature  already  made  by  the 
mother ;  but  more  often  she  only  complains  that  the  child's  "  hip  is 
growing  out "  or  that  she  is  "  round  shouldered  on  one  side."  Or 
the  condition  may  be  found  upon  routine  examination,  or  after  sus- 
picion is  excited  by  the  shape  of  the  thorax  observed  during  ex-^ 
amination  of  the  lungs. 

To  examine  for  spinal  curvature  it  is  best  to  have  the  patient,  if 
an  infant  or  young  child,  entirely  stripped  of  its  clothing.  A  girl 
or  older  child  should  at  least  be  stripped  to  the  level  of  the  tro- 
chanters and  the  shoes  removed.  The  patient  should  then  be 
directed  to  sit,  to  stand,  to  walk,  and  to  bend  over  forward  and  to 
lie  down.  The  sitting  and  standing  should  be  prolonged  sufficiently 
for  the  child  to  relax  the  muscles  and  unconsciously  assume  the 
habitual  attitude.  In  bending  over  forward  a  curvature  due  merely 
to  muscular  weakness  without  rotation  disappears ;  whereas,  if 
changes  in  the  skeleton  have  taken  place  they  cannot  be  thus 
obliterated.  One  should  compare  the  height  of  the  two  shoulders, 
which  often  serve  as  an  index  to  the  spinal  deviation,  and  also 
of  the  two  iliac  crests,  to  see  whether  the  pelvis  is  tilted.  When  the 
child  is  lying  level  on  his  back  on  a  plane  surface  one  raises  the  lower 
extremities  to  the  vertical  line  to  detect  any  difference  in  the  length 
of  the  limbs.  A  suspicion  of  a  curvature  may  sometimes  be  con- 
firmed by  correcting  it  by  placing  a  book  or  like  object  under  the 


430  SURGICAL  DISEASES  OF  CHILDREN 

short  limb  as  the  patient  stands,  or  under  one  buttock  as  the  patient 
sits.  Slight  deviations  can  be  shown  by  marking  with  crayon  the 
position  of  the  spinous  processes,  one  by  one,  until  the  line  is  evi- 
dent. As  the  child  lies  prone,  by  raising  his  legs  slowly  from  the 
table,  a  rickety  kyphosis  will  be  obliterated  or  almost  obliterated; 
but  an  angular  curvature  due  to  spinal  caries  will  remain.  Chang- 
ing the  patient's  attitude  will  demonstrate  how  nearly  the  deformity 
may  be  obliterated  by  muscular  action.  Suspension  by  head  and 
arms  will  show  what  could  be  accomplished  by  relief  from  weight- 
bearing  and  by  weightextension.  Subjective  symptoms,  as  aching 
or  tired  feelings  in  the  side  are  sometimes  complained  of,  with 
general  lassitude.  There  may  be  sharper  pain.  But  the  ache  or 
pain  is  usually  not  in  neck,  chest  or  abdomen  as  is  apt  to  be  the 
case  in  spinal  caries,  but  in  the  side.  The  scoliosometer  is  a  com- 
plicated instrument  and,  after  all,  hardly  as  accurate  as  the  prac- 
ticed eye.  Photographs  and  skiagraphs  are  very  useful  for  study, 
for  demonstration,  and  for  record. 

Prognosis. — Prognosis  is  good  in  the  functional  or  postural 
cases.  In  structural  or  fixed  deformity  little  can  be  expected  with- 
out exceptional  opportunities  for  treatment  and  unlimited  time,  un- 
less the  Abbott  method  shall  prove  to  be  what  it  is  hoped  and  ap- 
pears to  be. 

Treatment. — The  treatment  in  scoliosis  should  be  planned  ac- 
cording to  the  individual  case  and  with  regard  to  the  cause.  A 
very  slight  curvature  compensatory  to  a  shortened  limb,  unless  it  is 
increasing,  may  need  no  treatment  at  all.  Or  it  may  be  remedied 
by  raising  the  shoe  so  that  the  limbs  are  equal.  In  curvature  from 
empyema,  breathing  exercises  and  corrective  gymnastics  are  in 
order;  when  from  lateral  caries,  its  treatment  should  be  for  caries. 
If  a  constitutional  disease,  as  rachitis,  is  present  that  must  be 
treated  in  addition  to  the  corrective  posturings,  rest,  exercise, 
massage  and  corrective  manual  pressure  several  times  daily. 

If  the  general  cause  be  feebleness,  inherent  or  due  to  illness  or 
too  rapid  growth,  our  attention  must  be  directed  to  a  more  hygienic 
plan  of  living  and  to  tonic  treatment.  Mechanical  supports  have 
no  part  in  the  treatment  of  the  great  majority  of  functional  and 
rickety  curvatures  in  children.  Often  they  would  be  positively 
harmful.  Soft  beds  and  high  pillows  should  be  abolished.  Rest 
on  a  firm  mattress  with  a  plane  surface  or  with  a  spine  hammock 
or  sandbags  so  disposed  as  to  maintain  symmetry,  while  other  treat- 
ment for  the  feebleness  or  the  rickets  is  in  progress,  may  be  useful. 
Tiresome  or  sedentary  tasks  may  need  abatement  and  outdoor  life 
and  games  be  substituted.  In  short,  the  treatment  of  functional 
spinal  curvature  is  comprised  in  removing  the  cause,  improving  the 


THE  SPINE  431 

strength  and  tone  of  the  muscles,  and  in  correction  by  gymnastics. 
Until  recently  the  same  methods  have  been  applied  to  fixed  curva- 
tures, with  the  addition  of  braces,  jackets  or  corsets,  and  of  com- 
plicated and  powerful  machines,  calculated  to  forcibly  correct  the 
deformity.  Exercises  must  be  carefully  graduated  to  the  strength 
of  each  patient  and  should  not  fatigue.  After  each  stint  there 
should  be  a  few  minutes  rest  in  a  correct  position ;  and  when  the 
work  is  done  shampooing  the  muscles.^ 

Among  the  corrective  exercises  recommended,  I  have  found  the 
few  which  follow  very  useful : 

(i)  Breathing  and  Shoulder  Exercise. — The  patient  stands  erect;  arms 
at  side,  palms  forward,  and  takes  two  or  three  deep  breaths,  then  having 
filled  the  lungs  full,  he  raises  the  arms  over  his  head  and  still  further  ex- 
pands them.  With  the  lungs  filled  to  the  utmost,  he  brings  the  extended 
arms  from  the  vertical  to  the  horizontal  position  in  front  of  him,  with  palms 
forward,  as  though  pushing  the  air  before  him,  and  when  they  are  horizontal, 
he  sweeps  them  back  of  him,  as  though  in  the  act  of  swimming.  Repeat 
five  to  ten  times. 

(2)  Setting  up  Shoulders. — Breathing  deeply  meanwhile,  the  patient  ex- 
tends the  arms  outward  horizontally  and  circumducts  them,  keeping  them 
backward  to  the  limit — the  only  joint-motion  being  at  the  shoulder.  Repeat 
fifteen  or  twenty  circles. 

(3)  Spine  Extension  with  Exercise  of  Antero-posterior  Muscles. — • 
Hanging  from  a  horizontal  bar,  the  patient  swings  himself  by  throwing  his 
thighs  into  hyper-extension,  that  is,  backward,  allowing  gravity  to  give  the 
forward  swing.  Five  to  fifteen  times.  The  swinging  bar  may  be  used  at 
times  for  variety. 

(4)  Spine  Extension  with  Exercise  of  Lateral  Spinal  Muscles. — With  his 
hands  as  far  apart  as  comfortable,  grasping  the  bar,  he  swings  himself  from 
side  to  side  like  a  pendulum.     Five  to  fifteen  times. 

(5)  This  last  exercise  is  better  done  with  parallel  bars,  which  support 
the  patient  by  passing  under  the  axillse,  while  he  swings  from  side  to  side 
as  far  as  his  body  will  bend. 

(6)  Untwisting  the  Rotation  Actively  while  Suspended. — Hanging  in  this 
position  on  the  parallel  bars,  which  fix  his  shoulders,  the  patient  rotates  his 
pelvis  as  far  as  possible  toward  the  convex  side,  thus  untwisting  the  rota- 
tion.    Five  to  ten  times. 

(7)  Correcting  Rotation  Passively  while  Suspended. — Likewise  the  sur- 
geon may  grasp  the  patient's  body  suspended  with  both  hands  and  gently 
turn  it  in  the  direction  to  correct  the  rotation. 

(8)  Correcting  the  Convexity. — As  the  patient  hangs  suspended  either 
from  the  horizontal  bar  or  the  parallel  bars,  the  surgeon  with  his  hands 
pushes  against  the  convexity,  using  as  much  pressure  for  a  moment  or  two 
as  is  comfortable  to  the  patient. 

(9)  Thigh    Extension. — The   patient   lying  prone   upon  table,   couch   or 

1  Many  exercises  and  combinations  of  exercises  will  be  found  described  in 
the  writings  of  Busch,  Roth,  Gibney.  Alexander,  Shaw,  and  many  others. 
Wands,  dumbbells,  head  extension  appliance,  the  reclining  board,  the  quarter 
circle,  the  rowing  machine,  the  horizontal  bar  and  many  other  apparatuses 
may  be  used  if  convenient,  but  very  little  apparatus  is  absolutely  essential 
in  the  ordinary  run  of  children's  cases  of  functional  curvature. 


432  SURGICAL  DISEASES  OF  CHILDREN 

floor,  hyper-extends  his  thigh  while  the  limb  is  fully  extended,  lowers  it 
to  his  level  and  raises  it  again  five  to  ten  times.  The  hand  of  the  surgeon 
on  the  patient's  ankle  may  make  resistance. 

(lo)  Trunk  Extension. — The  patient  lies  upon  a  table  or  couch  with 
his  body  extending  over  the  end  while  the  surgeon  holds  the  legs  down 
to  his  level.  The  patient  then  lowers  his  shoulders  slowly  toward  the  floor 
and  returns  to  the  horizontal  again.  Repeating  three  to  ten  times  according 
to  his  strength. 

(ii)  Correcting  the  Rotation  Actively  while  Standing. — The  patient 
standing,  extends  his  hands,  palms  forward,  above  his  head  in  the  horizon- 
tal plane  of  the  body.  With  pelvis  fixed,  he  then  turns  his  shoulders,  face 
and  palms  as  far  as  possible  toward  the  concave  side,  pauses,  returns  to  posi- 
tion, facing  forward,  then  drops  hands  at  side.     Five  to  ten  times. 

(12)  Correcting  the  Concavity. — The  patient  extends  the  upper  ex- 
tremity of  the  convex  side  toward  the  horizontal.  The  upper  of  the  con- 
cave side  is  extended  high  above  the  head  and  circumducted  ten  or  twenty 
times.i 

Abbott's  method. — Abbott  has  devised  a  method  by  which  he 
is  able  to  correct  the  deformity  of  fixed  lateral  curvature  of  the 
spine.^ 

The  method  has  two  principles:  (i)  overcorrection;  (2)  fix- 
ation in  the  overcorrected  position  until  the  structures  are  so 
thoroughly  changed  that  they  will  not  resume  the  deformed  position. 
Abbott  maintains  that  the  usual  deformity  develops  with  the  spine 
flexed  and  bent  to  one  side  (either  right  or  left),  together  with  eleva- 
tion of  one  shoulder  (convex  side)  and  depression  of  the  other 
shoulder  (concave  side)  allowing  of  rotation  of  the  bodies  of  the 
vertebras  toward  the  convex  side.  To  correct  this  deformity  the 
integral  parts  involved  must  be  made  to  pass  through  the  same  route 
as  that  which  produced  the  deformity  but  in  the  reverse  order  and 
direction.  Therefore,  with  the  .patient  bent  strongly  forward,  the 
low  shoulder  must  be  elevated,  the  high  shoulder  depressed;  the 
bulging  ribs  must  be  drawn  downward  and  forward ;  and  lateral 
traction  must  be  made  against  the  lateral  curve;  and  while  in  this 
position  a  plaster  of  Paris  corset  must  be  applied.  A  special  ap- 
paratus is  necessary.  This  is  best  understood  by  referring  to  the 
illustrations.  Nine  of  the  rails  are  windlasses  with  rachets.  The 
hammock  of  light  duck  is  taut  at  one  edge  and  slack  at  the  other. 
The  patient  is  prepared  by  placing  upon  him  two  seamless  woven 
undershirts.  Saddler's  felt  is  used  over  all  bony  prominences,  heavy 
padding  back  of  the  low  shoulder,  over  the  sacrum,  over  the  spin- 
ous processes  of  the  ilium,  over  the  prominent  ribs  at  the  front  of 
the  thorax,  under  both  arms  and  over  the  convexity  of  the  ribs 

1  See  also  Klapp's  method  of  creeping  gymnastics   (Jour.  Am.  Med.  Assn., 
Feb.  24,  igo6)   in  Scoliasis  and  its  secondary  heart  disturbances. 

2E.  G.  Abbott:  New  York  Med.  Jour.,  June  24,  1911.     Ibid.  Apr.  27,  1912. 


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THE  SPINE  433 

where  the  band  is  to  be  appHecl  in  making  lateral  traction.  The 
pads  are  applied  by  slipping  them  into  position  between  the  two 
shirts.  If  the  patient  is  lean,  the  body  is  then  covered  also  by  wind- 
ing with  sheet-wadding.  The  patient  is  now  placed  face  upward, 
on  the  hammock  with  the  convex  ribs  pressing  next  to  the  taut 
side  of  it.  The  head  rests  upon  the  end  of  the  hammock,  between 
the  end  rod  and  a  strap  which  supports  the  hammock  beneath  the 
neck,  the  buttocks  rest  upon  the  adjustable  crosspiece  toward  the 
center  of  the  frame.  The  slack  side  of  the  hammock  gives  room 
for  the  depressed  ribs  to  be  pushed  backward  (i.e.  toward  the  floor). 
The  patient's  lower  limbs  are  now  hoisted  upward  and  toward  his 
head,  so  that  the  spine  is  strongly  flexed.  Straps  of  muslin  are  now 
applied  around  the  body  and  fastened  to  the  bars  of  the  frame  which 
can  be  made  to  wind  them  and  so  pull  the  body  in  any  desired  direc- 
tion. One  strap  is  passed  under  the  low  axilla  and  the  ends  carried 
laterally  and  obliquely  upward  to  the  opposite  side.  A  second  is 
passed  around  the  buttocks  and  draws  them  toward  the  same  side 
as  the  first.  The  third  strap  is  passed  around  the  body  at  the  most 
convex  portion  of  the  curvature  and  wound  upon  the  upper  rail  of 
the  main  frame.  Traction  upon  this  strap  obliterates  the  curvature 
or  produces  a  curve  in  the  opposite  direction.  A  fourth  strap  is 
used  only  if  the  curvature  is  very  rigid  and  very  rapid  reduction 
is  desired.  It  should  be  at  least  four  inches  in  width  and  is  used 
by  first  fastening  it  to  the  upper  rail  of  the  main  frame,  on  the  side 
to  which  the  axilla  and  buttock-straps  are  fastened,  then  passing 
it  across  the  body  and  hanging  weights  upon  its  lower  end.  Its 
object  is  to  exert  force  against  the  anterior  protruding  ribs  to  press 
them  backward  (downward)  against  the  slack  side  of  the  hammock. 
It  may  be  wound  on  a  lower  rail  or  its  pull  changed  by  guys. 
The  arm  of  the  low  shoulder  is  elevated  as  far  as  possible  and  held 
by  an  assistant.  The  other  arm  rests  on  the  frame  rail,  at  a  little 
less  than  right  angle  with  the  body.  The  frame  may  be  tilted  or 
the  lower  limbs  further  elevated  to  exaggerate  the  position.  If  now 
the  overcorrection  is  deemed  sufficient,  or  if  this  is  not  to  be  the  only 
corset,  but  the  first  of  a  series,  the  patient  is  ready  for  the  plaster. 
But  if  it  is  preferred  to  use  a  single  corset  and  yet  make  still 
further  correction,  it  is  necessary  now  to  apply  a  thick  oval-shaped 
pad  of  felt  over  the  concave  side  and  back  of  the  body,  so  that 
when,  subsequently,  the  window  is  cut  in  the  corset  and  this  pad 
removed  it  leaves  room  for  the  ribs  to  be  pushed  farther  backward 
and  the  spine  to  be  more  overcorrected  by  pads  placed  in  the  front 
and  sides.  The  plaster  of  Paris  is  applied  as  in  any  corset,  except- 
ing that,  over  the  shoulder  that  has  been  elevated,  it  is  extended 
posteriorly  as  high  as  the  acromion  process.     In  trimming,  the  bot- 


434  SURGICAL  DISEASES  OF  CHILDREN 

torn  of  the  corset  is  cut  shorter  in  front  and  longer  behind  than 
ordinary.  The  upper  edge  is  trimmed  very  high  beneath  the  ele- 
vated arm,  but  cut  away  in  front,  so  that  the  shoulder  may  come 
forward.  Beneath  the  other  arm  it  is  cut  low,  but  high  in  front 
so  that  this  shoulder  cannot  drop  forward,  and  cut  out  behind  so 
that  the  shoulder  may  come  backward.  A  large  window  is  cut  in 
the  back  of  the  corset  over  that  part  where  the  ribs  were  depressed, 
so  that  they  may  push  backward,  and  extending  toward  the  side  to 
allow  further  overcorrection  laterally.  A  second  window  is  cut  on 
the  opposite  side  in  front,  allowing  the  ribs  which  were  bulging 
posteriorly  to  push  forward.  Patients  are  able  to  be  dressed  and 
walk  about  with  the  corset.  Further  overcorrection  may  be  ob- 
tained if  desired,  by  the  use  of  felt  pads,  at  intervals  of  a  few  days 
or  a  week,  as  the  body  yields  to  the  pressure.  These  pads  are 
slipped  in  through  the  windows,  especially  in  front  to  push  the  ribs 
backward  through  the  window  cut  behind;  and  sometimes  (but  less 
effectively),  they  are  placed  in  at  the  side  over  the  convexity  of  the 
lateral  curve.  Pads  are  used  only  as  yielding  allows  and  then  only 
of  such  thickness  as  will  not  cause  too  painful  a  pressure.  Bro- 
mides may  be  used  as  a  sedative.  This  padding  process  is  re- 
peated, with  the  same  corset  until  satisfactory  overcorrection  is  at- 
tained ;  or  new  corsets  may  be  applied.  Overcorrection  may  require 
three  to  six  weeks  time,  more  or  less.  The  corset  is  then  worn 
until  the  structures  have  had  time  to  adapt  themselves  permanently 
to  the  new  position,  which  may  require  two  or  three  months  or 
more.  A  course  of  exercises  and  massage  follows,  generally  with 
a  light  brace  in  overcorrection,  until  complete  restoration  to  normal. 

TUBERCULOSIS  OF  THE  SPINE  (POTT'S  DISEASE; 
CARIES  OF  THE  SPINE;  SPONDYLITIS) 

Etiology  and  Pathology.— Utreditary  vulnerability,  diseases 
which  lower  vitality,  notably  the  infections  like  measles,  scarlet  fever 
and  whooping-cough,  prepare  the  way  for  vertebral  tubercular  caries. 
Traumatism  undoubtedly  frequently  locates  the  point  of  attack. 
Yet  cases  occur  where  there  has  been  no  known  hereditary  tendency, 
no  previous  illness,  and  no  possible  injury.  Neither  sex  enjoys 
greater  immunity  than  the  other,  and  no  age  is  exempt.  (See 
Section  on  Tuberculosis.)  The  lesion  consists  in  a  tubercular 
inflammation,  running  the  slow  but  persistent  course  of  years 
characteristic  of  this  disease,  softening  the  bone  by  a  process  of 
rarefying  osteitis,  absorbing  the  cancellous  tissue  or  changing  it  to 
granulation  tissue  which  breaks  down  into  cheesy  semifluid  material 
resembling  pus,  making  a  "  spinal  abscess."  There  may  or  may  not 
be  sequestra.  Or  the  softened  material  may  be  reabsorbed  and  car- 
ried away  by  lymph  or  blood  channels — so-called  "  dry  caries."     Or 


THE   SPINE  435 

after  abscess  has  formed  it  may  be  absorbed,  as  sometimes  occurs 
elsewhere,  Jeaving*  a  dry,  cheesy  or  cretaceous  mass.  If  injury  occur 
or  the  patient's  vitaHty  be  lowered  by  illness,  or  the  cheesy  deposit 
become  infected  with  pyogenic  organisms,  it  may  break  down  and 
become  a  "  residual  abscess."  If  the  original  infection  be  a  mixed 
infection,  that  is,  not  only  by  the  bacillus  tuberculosis  but  by  pyo- 
genic organisms  as  well,  or  they  later  gain  access  to  the  focus  of 
disease,  the  destruction  is  much  larger  and  more  rapid,  being  an 
affair  of  months  instead  of  years.  The  disease  process  generally 
affects  the  bodies  of  the  vertebrae,  beginning  near  the  epiphyseal 
line.  One  or  several  contiguous,  vertebrae  may  be  diseased,  with  de- 
struction also  of  the  intervertebral  discs,  or  there  may  be  more  than 
one  focus,  with  sound  vertebrae  intervening.  There  may  be  coexist- 
ent tubercular  disease  of  other  bones  or  joints,  lymphatic  glands  or 
viscera  remote  from  the  spinal  disease.  The  disease  being  in  the 
bodies  of  the  vertebrae  and  very  rarely  extending  to  transverse  or 
spinous  processes,  it  follows  that  when  softening  of  the  bodies  takes 
place  the  column  collapses  on  its  anterior  side,  being*  supported  by 
the  arches  and  spinous  processes  posteriorly.  This  produces  the 
deformity  of  the  disease,  namely,  angular  curvature  or  kyphosis, 
small  if  only  one  vertebra  has  collapsed,  larger  in  proportion  if  more 
than  one,  but  always  pointed  posteriorly  more  acutely  than  curva- 
ture from  any  other  cause.  As  the  disease  continues,  nature  en- 
deavors to  protect  herself  by  building  up  osseous  walls  around  the 
seat  of  the  disease;  so  that  if  recovery  follows  one  finds  what  re- 
mained of  the  distorted  vertebrae  cemented  together  in  their  new 
position  by  masses  of  newly  formed  bone.  The  "  abscess  "  of  tuber- 
cular spondylitis  is  not  strictly  speaking  an  abscess.  The  material 
it  contains  is  not  true  pus  unless  pyogenic  organisms  have  gained 
access.  The  content  of  the  so-called  spinal  abscess  may  be  quite 
liquid  or  semi-solid,  and  vary  in  color  from  pale  straw  color  to  dark 
yellow.  It  may  hold  also  spiculae  of  bone  or  sequestrae  of  consider- 
able size.  The  collection  may  be  small  or  large,  may  be  confined 
by  the  inflammatory  thickening  of  surrounding  tissues,  or  as  it  ac- 
cumulates and  tension  increases,  it  may  find  its  way  in  the  direction 
of  least  resistance  between  surrounding  structures,  often  burrowing 
along  fascial  planes  until  it  finds  exit  upon  the  surface  of  the  body, 
or  into  some  cavity  or  viscus  perhaps  far  distant  from  its  source. 
Caries  may  be  located  in  any  vertebra  or  in  a  number  of  them.  A 
resultant  abscess  will  present  clinical  features  according  to  its  loca- 
tion. Cervical  caries  may  form  an  abscess  appearing  in  the  post- 
pharj'ngeal  region  (see  Section  on  Chronic  Retro-pharyngeal  Ab- 
scess) or  at  the  side  of  the  neck  before  or  behind  the  sterno-mas- 
toid  muscle,  or  it  may  burrow  into  the  mediastinum  or  pleural  cavity^ 


436 


SURGICAL    DISEASES    OF    CHILDREN 


or  into  the  esophagus,  trachea,  or  a  bronchus.  Dorsal  abscess  may 
open  into  any  part  of  the  intestine,  or  into  the  bladder;  or  more 
commonly  it  will  be  retained  by  the  sheath  of  the  psoas,  following  it 
down  beneath  Poupart's  ligament  and  there  protruding  beneath  the 
skin,  which,  if  left  to  itself,  it  would  finally  burst  through,  or  track 

farther  down  the  thigh. 
(See  Fig.  156.)  Lumbar 
spinal  abscess  may  follow 
the  same  course,  or  may 
appear  in  the  gluteal  re- 
gion, or  upon  the  back 
just  outside  of  the  quad- 
ratus  lumborum. 

It  would  seem  hardly 
possible  that  a  process  de- 
structive of  bone  and  re- 
sulting in  abscess  could 
take  place  without  obvious 
symptoms.  And  yet  cases 
occur  unsuspected  until  a 
swelling,  perhaps  in  Scar- 
pa's triangle,  betrays  the 
presence  of  spinal  abscess 
tracked  down  from  the  dor- 
sal or  lumbar  region. 

Symptoms  and  Diagno- 
sis.— The  symptoms  and 
signs  by  which  the  disease 
may  be  diagnosed,  in  the 
majority  of  cases,  begin 
early  in  the  disease  but  are  often  so  obscure  as  to  pass  unaccounted 
for  at  the  time.  The  prominent  ones  are  lassitude  and  peevishness, 
tenderness,  pain,  attitude  and  movements,  rigidity,  psoas  spasm,  de- 
formity, abscess,  nervous  symptoms.  The  child  shows  disinclination 
to  play  as  usual,  or,  after  beginning  an  active  game,  desists  and 
chooses  a  sedentary  one,  or  grows  fretful  and  lies  down.  This  may 
continue  for  several  days  or  weeks,  and  if  by  any  good  fortune  the 
child  be  carefully  examined  during  this  time  it  is  not  probable  that 
anything  farther  could  be  discovered  except  that  he  does  not  like  to 
jump  or  receive  any  jar  in  the  long  axis  oi  the  spine.  The  tender- 
ness is  not  evident  to  external  pressure  or  percussion,  but  uncon- 
sciously the  child  avoids  jarring.  Pain  may  be  complained  of  in  the 
head,  neck,  throat,  or  chest,  and  be  accompanied  with  difficulty  in 
swallowing  or  choking  sensations  if  the  trouble  is  cervical;  it  may 
be  in  the  chest  if  high  dorsal,  in  the  belly  if  low  dorsal,  and  down 


Fig.  151.  Boy  with  spinal  caries  in 
the  act  of  stooping  to  touch  the  floor. 
The  spine  is  held  rigidly  straight  and 
supported  by  a   hand  upon  the  thigh. 


THE   SPINE 


437 


the  thighs  if  lumbo-sacral.  The  pain  is  intermittent  and  is  hard 
for  the  child  to  locate.  The  pain  persists.  It  will  not  be  banished 
like  an  ordinary  "  belly-ache,"  but  returns  day  after  day.  It  may 
get  worse  in  the  early  part  of  the  night.  The  pain  of  malignant 
disease  of  the  spine  is  severe  and  constant,  not  relieved  by  rest  in 
bed,  and  the  patient  is 
cachectic  in  appearance. 
Paralysis  appears  early 
with  malignant  disease 
as  compared  with  caries. 
In  some  cases  one  must 
await  developments  be- 
fore deciding  between 
malignant  disease  and 
caries.  The  pain  of 
rheumatic  spine  is  apt 
to  be  more  diffused,  or, 
if  localized,  to  be  more 
severe  on  motion,  there 
are  rheumatic  symptoms 
in  other  joints,  and  the 
whole  course  of  the  dis- 
ease is  more  acute. 
Rickety  curvature  causes 
no  pain.  If  lateral  cur- 
vature causes  pain  it 
seldom  occurs  until  the 
deformity  is  so  marked 
that  there  need  be  no 
difficulty  in  the  diag- 
nosis. The  pain  in  hys- 
terical spine  is  produced 
by  light  touch  which  has 
little    effect    in    causing 


Fig.  152.  Child  with  lower  dorsal  caries. 
Showing  characteristic  attitude,  seeking 
support  for  the   spine. 


pain  in  spinal  caries. 

Probably  by  this  time, 
if  not  before,  muscular  rigidity  has  become  evident  by  attitude 
and  restricted  motion.  The  child  walks  as  if  he  were  afraid  of  the 
slight  jar  of  each  step.  He  carries  his  feet  low  and  moves  cau- 
tiously as  if  he  were  balancing  a  weight  upon  his  head.  With  dis- 
ease in  the  dorsal  or  lumbar  region,  if  he  is  asked  to  pick  up  an 
object  from  the  floor,  he  will  not  bend  over  to  reach  it,  but  will  squat 
down  by  flexing  knees  and  thighs,  without  arching  the  spine.  (See 
Figs.  151  and  155.)  Perhaps  he  will  support  the  spine  b]*  resting 
the  hands  upon  knees  or  thighs,  or  will  raise  himself  in  the  same 


438  SURGICAL   DISEASES    OF   CHILDREN 

manner.     Or  he  will  support  himself  by  holding  on  to  a  table  or  a 
chair  or  by  leaning  over  a  chair.     (See  Figs.  152  and  154.) 

If  the  child  is  laid  prone  on  the  table  and  the  spine  be  hyper- 
extended  by  lifting  his  feet,  the  rigidity  of  the  diseased  portion  of 
the  column  will   contrast  clearly  with  the  flexibility  of  a  normal 
■  spine.     This  muscular  fixation  is  a  most  important  sign.     (See  Fig. 
153.)     There  is  no  such  rigidity  in  lateral  curvature,  nor  in  hysteri- 


FiG.   153.     Caries  of  the  spine.     Showing  muscular  rigidity  upon  attempt- 
ing flexion   of  the   lumbo-sacral  region,  which  is   diseased. 

cal  spine.  With  the  child  still  lying  prone  the  thighs  should  be 
hyper-extended,  one  at  a  time,  by  flexing  the  leg  to  a  right  angle 
with  the  thigh  and  then  lifting  it  vertically  from  the  table.  If 
spondylitis  be  present  in  the  lower  dorsal  or  lumbar  regions,  this 
over-extension  of  the  psoas  muscle  will  cause  its  reflex  rigidity  to 
yield  with  a  characteristic  tremulous  spasmodic  twitching  known  as 
psoas  spasm.  This  may  be  present  upon  one  or  both  sides.  These 
cases  with  psoas  spasm  should  be  carefully  differentiated  from  hip- 
joint  disease,  and  from  sacro-iliac  disease. 

Peculiar  attitude,  restricted  movements,  rigidity  of  the  muscles 
of  the  affected  region  are  equally  marked  in  cervical  caries.  The 
child  is  apt,  while  sitting,  to  rest  the  elbows  on  the  knees  and  support 
the  head  with  the  hands.  Normally  the  head  of  the  young  child  can 
be  rotated  at  the  atlanto-axial  articulation  through  a  quarter  of  a 
circle,  and  by  employing  also  the  other  cervical  articulations  it  can 
be  turned .  through  nearly  a  half  circle.  It  can  be  fully  flexed  and 
extended.  In  cervical  caries  the  head  is  not  willingly  rotated  at  all, 
this  motion  being  most  strictly  limited  in  occipito-atloid  or  atlanto- 
axial disease.  Flexion  and  extension  also  are  inhibited  by  the  reflex 
muscular  spasm,  this  being  especially  marked  if  the  cervical  disease 
is  below  the  axis.  The  child  draws  up  the  shoulders  and  settles  the 
head  between  them  as  if  by  that  means  to  prevent  motion.  If  asked 
to  look  to  either  side,  he  turns  the  shoulders  with  the  head.  The  at- 
titude sometimes  much  resembles  at  first  glance  that  of  torticollis. 
But  the  shoulders  are  not  so  elevated  in  torticollis,  and  the  face  is 


THE  SPINE 


439 


turned  away  from  the  contracted  muscles.  Whereas  with  caries  the 
face  is  turned  toward  the  contraction.  In  the  majority  of  cases  of 
cervical  tuberculosis  it  is  the  flexor  and  extensor  muscles  that  are 
reflexly  contracted ;  while  in  wry- 
neck it  is  most  often  the  sterno- 
mastoid  that  is  fixed. 

Deformity  is  an  early  and  char- 
acteristic sign  of  caries.  Typi- 
cally it  is  a  sharp  antero-posterior 
curvature,  one  or  more  vertebrae 
being  involved  in  the  formation  of 
the  angle,  thus  making  it  smaller 
or  larger,  but  is  always  more 
pointed  posteriorly  than  a  curva- 
ture produced  by  any  other  con- 
dition can  be.  A  rickety  spinal 
curvature  usually  involves  quite 
a  number  of  vertebrae,  making  a 
much  longer,  rounded  projection 
posteriorly,  which  can  almost  if 
not  quite  be  obliterated  by  the 
flexibility  test.  Moreover,  with 
the  rickety  spine,  there  are  almost 
always  other  evidences  in  the 
skeleton — the  cranial  bosses,  bead- 
ed ribs,  enlarged  radial  epiphyses, 
bowed  arms  or  legs.  The  prom- 
inence of  the  carious  kyphos  va- 
ries somewhat  also  with  the  region 
of  spine  affected.  In  the  dorsal 
region,  which  is  normally  con- 
vexed  posteriorly,  it  projects 
more  than  in  the  lumbar  or  cervi- 
cal, which  is  concave  posteriorly. 
In  the  lumbar  region  particularly 
a  deformity  seems  to  appear  late, 
and  is  harder  to  detect,  its  first 
evidence  being  an  abnormal 
straightness  of  the  affected  re- 
gion rather  than  a  projection, 
which  comes  later.  (See  Fig. 
I55-) 

The  nervous  symptoms  accompanying  spinal  caries  are  sensory, 
motor  or  trophic.  Pain  (and  its  regional  distribution)  has  been  re- 
ferred to  as  one  of  the  earlier  symptoms.    Later  the  skin  in  certain 


Fig.      154.        DORSO-LUMBAR     CARIES. 

Boy  of  7  years.     Kyphos  begin- 
ning to  show. 


440 


SURGICAL   DISEASES    OF   CHILDREN 


Fig.  155.  Beginning  dorso- 

LUMBAR     CARIES.       No     kyphos 

yet  visible.  Holds  spine  rig- 
idly erect.  Walks  carefully 
with  his  shoulders  held  back 
in  position  seen  in  the  illus- 
tration. Will  not  bend  to 
pick  up  an  object,  but  squats 
down.  Complains  of  pains 
in  belly.     Boy  of  6  years. 


areas  may  become  hyperesthetic. 
Patches  of  the  skin  may  become  anes- 
thetic, although  the  seat  of  subjective 
pain,  and  the  reflex  movements  be 
diminished. 

With  the  exception  of  an  exagger- 
ated plantar  reflex,  which  may  appear 
early,  motor  symptoms  are  later  in 
their  appearance  than  sensory,  and 
may  be  severe  enough  in  upper  cervi- 
cal caries  to  seriously  impair  the  ac- 
tion of  the  intercostal  muscles  and 
diaphragm ;  and  in  lumbar  caries  to 
produce  paraplegia,  with  paralyzed 
rectum  and  bladder,  and  lost  patellar 
reflex.  Trophic  symptoms  are  usually 
last  to  appear,  the  muscles  wasting 
extremely ;  but  bedsores  are  not  so 
easily  produced  as  might  be  expected. 

The  nervous  symptoms  result  either 
from  changes  in  the  spinal  nerves 
where  they  emerge  from  the  spinal 
canal,  or  to  disease  of  the  cord  itself 
at  their  point  of  origin,  set  up  by  the 
proximity  of  the  inflammation  or  re- 
sulting pressure  upon  the  cord.  The 
arteries  of  the  cord  may  be  com- 
pressed by  inflammation  of  lymphatic 
tissues  near  them.  Spinal  abscess 
may  burrow  in  the  canal  and  com- 
press the  cord.  Hemorrhage  may  act 
the  same  way.  When,  as  is  com- 
monly the  case,  the  inflammatory  soft- 
ening affects  only  the  anterior  Dor- 
tions  of  the  bodies  of  the  vertebrae, 
leaving  the  arches  and  posterior  parts 
of  the  bodies  unaffected,  it  is  very  rare 
for  the  curvature  itself,  however  acute 
it  may  be,  to  compress  the  cord  or 
nerves.  But  in  those  more  unusual 
cases  where  the  laminae  and  posterior 
portions  of  the  bodies  are  affected, 
are  found  the  most  marked  nervous 
symptoms  even  though  there  be  little 
angulation.      One   of   the   most   com- 


THE    SPINE 


441 


mon  causes  of  compression  is  the  growth  of  masses  of  granulation 
tissue,  so-called  granuloma,  within  the  canal.  A  rare  cause  is  sudden 
collapse  of  carious  vertebrae,  producing  prompt  paraplegia.  Pressure 
upon  or  laceration  of  the  cord 
have  sometimes  been  produced 
by    sequestra. 

Only  the  sensory  disturbances, 
appearing  early,  are  likely  to  be 
puzzling  as  to  their  point  of 
origin.  Usually  in  the  cases  pre- 
senting paralysis  the  disease  is 
more  advanced  and  a  kyphos  is 
sufficiently  in  evidence  to  aid  in 
the  diagnosis.  (35) 

With  the  hysterical  spine,  pres- 
sure over  the  spinous  processes 
elicits  great  complaint.  The  ca- 
rious spine  is  usually  not  very 
sensitive  to  pressure  of  the  hand 
upon  the  back. 

Abscess  in  its  various  locations 
has  been  described  under  the 
pathology.  It  is  apt  to  occur  in 
the  majority  of  untreated  cases; 
and  will  sometimes  occur  in  spite 
of  the  best-directed  treatment.  It 
may  come  quite  insidiously,  with- 
out giving  rise  to  any  additional 
symptoms,  but  usually  with  the 
formation  of  the  abscess  there  is 
an  increase  of  the  pain,  restric- 
tion of  movement,  muscular  rig- 
idity, and  also  a  greater  impair- 
ment of  the  general  health. 

The  symptoms  and  diagnosis  of 
abscesses  resulting  from  cervical 
caries  will  be  found  under  the 
heading  of  retro-pharyngeal  ab- 
scess. 

In  suspected  dorsal  or  lumbar 
caries  if  no  abscess  be  found 
pointing  externally  anywhere  in 
the  usual  situations  in  the  iliac, 
inguinal,  or  lumbar  regions,  or  more  rarely  about  the  gluteal  region 
or  thigh,  search  should  be  made  to  detect  it  more  deeply  located. 


Fig.  156.  Typical  dorsal  caries, 
and  also  hip-joint  disease. 
Boy  12  years  old.  Diseased 
since  2d  year.  Two  years  ago 
sinuses  on  thigh  were  irri- 
gated with  creolin  solution, 
some  of  which  the  boy 
coughed  up  after  each  irri- 
gation. 


442  SURGICAL  DISEASES    OF   CHILDREN 

With  the  child  lying  upon  his  back  and  his  thighs  flexed  and  abdom- 
inal muscles  relaxed,  deep  palpation  along  the  course  of  the  psoas 
muscle  may  reveal  the  presence  of  abscess.  Digital  exploration  per 
rectum  may  furnish  information  of  value;  especially  in  differentiat- 
ing from  sacro-iliac  disease.  Careful  percussion  and  palpation  about 
the  loins  should  be  employed.  Abscess  must  be  differentiated  from 
hernise  and  tumors.  Abscesses  are  dull  on  percussion,  fluctuate,  and 
on  pressure  disappear  gradually  without  gurgling.  Hernias  generally 
appear  in  the  hernial  canals,  are  somewhat  tympanitic  on  percussion, 
and,  on  applying  the  taxis,  are  apt  to  gurgle,  and  when  they  disap- 
pear do  so  suddenly.    Either  may  have  an  impulse  on  coughing. 

A  history  of  typhoid  fever  preceding  spinal  symptoms  will  direct 
attention  to  that  form  of  osteitis  or  periostitis  called  the  typhoid 
spine. 

Acute  septic  osteomyelitis  may  attack  the  spine.  It  is  apt 
to  affect  a  number  of  the  vertebrae  at  once  and  very  acutely  and 
violently. 

Syphilitic  disease  of  the  vertebrae  may  occur.  If  this  is  borne 
in  mind  other  syphilitic  lesions,  scars,  or  the  history  will  prevent 
a  mistake,  and  the  therapeutic  test  confirm  the  diagnosis. 

Prognosis. — Pott's  disease  of  the  spine  may  result  in  recovery 
with  more  or  less  deformity,  or  in  death  by  exhaustion  from  the  dis- 
charges, general  tuberculosis,  amyloid  disease  with  albuminuria,  from 
the  bursting  of  abscess  internally,  general  sepsis  from  infection  of 
abscess  open  externally,  meningitis,  peritonitis,  myelitis.  Hemor- 
rhage from  erosion  of  a  blood-vessel  by  abscess  may  cause  death. 
Tubercular  meningitis  is  more  common  in  children  than  in  adults ; 
and  pulmonary  phthisis  less  so. 

The  prognosis  in  children  is  better  than  in  adults.  Prognosis 
is  much  better  if  the  disease  is  discovered  and  treatment  instituted 
before  the  formation  of  abscess  than  after  abscess  has  formed.  The 
disease  is  always  chronic,  running  a  course  of  months  or  years  even 
in  favorable  cases. 

The  symptoms  may  be  ameliorated  and  improvement  be  inaugu- 
rated in  a  few  months  or  even  in  a  few  weeks,  but  a  cure  is  not  to  be 
expected  short  of  several  years.  The  expectancy  of  life  following 
cured  spondylitis  is  according  to  the  severity  of  the  lesions  as  evi- 
denced by  the  amount  of  resultant  deformity.  Every  patient  who  sur- 
vives Pott's  disease  of  the  spine  will  be  permanently  deformed.  The 
peculiarities  of  the  deformity  will  vary  somewhat  according  to  the 
region  diseased  and  the  amount  of  destruction  of  bone.  But  there 
is  always  shortening  of  the  body  which  makes  the  arms  and  legs 
appear  disproportionately  lengthened,  and  in  walking  the  arms  are 
swung  backward  to  maintain  the  equilibrium.  Dorsal  caries  pro- 
duces deformity  of  the  sternum,  and  often  an  alteration  of  the  voice. 


THE    SPINE  443 

Motor  paralysis  indicates  a  severe  and  advanced  condition  but 
does  not  preclude  recovery  both  from  the  disease  and  the  paralysis. 

Sensory  paralysis  and  spastic  contractures  of  muscles  indicate 
disease  of  the  cord  itself,  and  therefore  darken  the  prognosis,  but  do 
not  make  it  hopeless. 

Treatment. — The  first  principle  involved  in  the  treatment  of 
tubercular  spine  is  that  of  rest.  Partial  rest  can  be  secured  by 
removing  superincumbent  weight,  or  by  preventing  motion.  Com- 
plete rest  can  be  secured  only  by  both  removing  superincumbent 
weight  and  preventing  motion.  This  is  best  done  by  placing  the 
patient  horizontally  on  a  flat  mattress  and  using  also  a  fixative  splint, 
brace,  jacket,  or  other  apparatus.  In  practice  various  modifications 
of  this  rule  are  in  vogue — concessions  to  the  wishes  of  the  friends 
of  the  patient  or  the  patient  himself,  who  does  not  want  to  stay  in 
bed,  or  does  not  want  to  wear  a  jacket  or  brace.  But  that  does  not 
alter  the  principle  involved ;  and  I  am  quite  certain,  from  personal 
observation,  that  many  a  case  of  spinal  caries  which  might  have  been 
cured  within  a  reasonable  time,  with  little  suffering  and  slight  re- 
sulting deformity,  has  been  dallied  with  in  halfway  measures  until 
abscess,  kyphosis,  and  nervous  phenomena  have  demonstrated  serious 
advances  of  the  disease  and  forever  precluded  a  satisfactory  course 
and  termination.  It  is  true  that  many  cases  do  perfectly  well  by  tak- 
ing off  weight  alone,  keeping  them  in  bed  on  a  flat  mattress,  especially 
if  they  are  adolescents  or  adults.  With  children,  who  by  comparison 
are  much  more  restless,  fidgety,  and  thoughtless  of  consequences, 
this  is  not  so  apt  to  succeed.  It  is  true  also  that  many  cases  recover 
with  the  use  of  jackets,  braces,  or  other  fixing  apparatus  which  pre- 
vent motion,  the  patient  being  in  the  meantime  allowed  his  liberty, 
going  about,  indoors  and  out  of  doors.  Nevertheless  it  is  more  safe 
and  certain,  on  undertaking  a  case  of  spinal  caries  in  a  child,  to  take 
off  the  weight  by  putting  the  patient  to  bed,  and  to  secure  immobility 
by  applying  such  means  as  may  be  necessary  according  to  the  loca- 
tion and  stage  of  the  disease,  and  the  behavior  of  the  patient.  These 
thorough  measures  will  usually  arrest  the  disease  as  promptly  as  it 
can  be  done,  will  aid  in  improving  the  general  health  of  the  patient 
and  start  him  on  the  road  to  recovery.  Then,  perhaps,  after  a  few 
weeks  or  months,  or  sometimes  even  a  year,  of  complete  rest,  he  can 
be  allowed  to  go  about  with  a  jacket,  jury  mast,  leathern  collar,  or 
other  apparatus.  I  am  well  aware  of  the  objections  urged  against 
confining  a  patient  to  bed.  "  It  will  weaken  him  to  lie  in  bed."  "  It 
will  keep  him  shut  up  indoors  too  much."  "  He  will  not  get  any 
exercise."  Not  one  of  these  objections  is  valid.  Every  surgeon  who 
has  had  experience  with  this  disease  and  this  plan  of  treatment  has 
seen  patients  who  are  suffering  pain,  who  are  having  bad  nights  and 
fretful,  worrysome  days,  who  are  pale,  losing  weight,  and  failing  in 


444 


SURGICAL  DISEASES  OF  CHILDREN 


appetite  and  strength,  make  a  complete  change  in  a  few  weeks  by 
putting  them  at  rest  in  bed.  Pain  is  reheved,  quiet  sleep  is  restored, 
appetite  and  cheerfulness  return,  improved  color  and  increased 
weight  are  apparent,  and  strength  of  heart  muscle,  and  of  volun- 
tary muscles  is  really  augmented.  Rest  of  the  spine  in  bed  does 
not  preclude  open  air  and  sunshine,  massage  and  passive  exercise 
and  active  exercise  of  the  extremities.  Bradford  and  Lovett  have 
stated  their  opinion  that  the  tendency  to  tubercular  meningitis  is  in- 
creased by  prolonged  recumbency. 
But  the  spinal  tuberculosis  is  already 
present  and  active  and  the  meningeal 
involvement  only  a  possibility.  This 
possibility  only  makes  it  the  more 
necessary  to  control  the  active  pro- 
cess as  promptly  as  possible  by 
thorough  treatment  from  the  ear- 
liest discovery  of  the  condition.  To 
secure*  rest  of  the  spine  we  may  re- 
sort to  sandbags,  the  frame,  the 
jacket,  the  brace,  the  collar  or  head 
extension.  The  frame,  one  of  the 
best  means,  is  made  of  gaspipe, 
wood  or  bamboo,  upon  which  canvas 
is  stretched.  The  frame  is  arched  to 
any  desired  convexity  or  left  flat  with 
a  light  steel  arch  superimposed. 
Fenestration  and  felt  pads  prevent 
undue  pressure  upon  the  kyphosis. 
A  second  fenestration  under  the  but- 
tocks makes  care  of  the  dejections  easy.  Jackets  are  made  of 
plaster  of  Paris,  leather,  poroplastic  felt,  aluminum,  rawhide,  paper, 
etc.  For  general  usefulness  and  cheapness  nothing  compares  with 
gypsum;  and  it  is  sometimes  an  advantage  to  have  a  jacket  that 
cannot  be  removed  by  the  patient.  By  means  of  a  strip  of  muslin 
passed  beneath  the  jacket  and  projecting  at  both  ends  and  the  use 
of  alcohol  and  powders  the  skin  can  be  kept  sound.  A  new  jacket 
may  be  needed  once  in  a  month  or  three  or  six  months. 

Every  surgeon  knows  how  to  put  on  a  good  plaster  jacket.  The 
rules  are  simple — yet  not  every  surgeon  puts  on  a  good  plaster 
jacket.  There  is  an  art  in  it.  Before  the  plaster  is  applied  a  snugly 
fitting  undershirt  or  stockinet  is  put  on.  A  plaster  jacket  may  be 
applied  with  the  patient  partially  suspended,  his  heels  off  the  floor. 
But  he  is  usually  laid  prone  upon  a  strip  of  strong  unbleached  mus- 
lin which  is  stretched  lengthwise  upon  a  frame,  having  a  windlass 


Fig.  157.    Leather  jacket  for 
spinal  caries. 


THE  SPINE  445 

at  one  end.  By  adjusting  the  tension  of  the  musHn  a  degree  of 
straightening  of  the  spinal  curvature  may  be  secured  (36)  ;  but  no 
forcible  correction  should  be  attempted.  Pads  of  felt  or  prepared 
wool  or  cotton  batting  should  protect  bony  prominences,  for  in- 
stance the  iliac  crests  and  the  kyphosis.  In  developing  girls,  pads 
which  can  afterward  be  removed  should  prevent  undue  pressure  on 
the  mammae.  The  "dinner  pad"  is  not  usually  necessary.  A  three 
to  six  inch  plaster  bandage,  five  yards  long,  is  convenient.  Each 
bandage  should  be  immersed  in  water  until  air  bubbles  cease  to  rise 
from  it.  Beginning  at  the  level  of  the  trochanters  the  bandage  is 
quickly  applied  encircling  the  body  and  rising  half  a  width  at  a 
time  until  the  arms  are  reached.  Each  layer  should  be  smoothly 
pressed  down  upon  that  beneath.  When  the  jacket  is  sufficiently 
thick,  the  patient  should  be  kept  in  correct  position  until  the  plaster 
sets.  The  muslin  support  is  then  cut  across  at  the  upper  and  lower 
ends  of  the  jacket  and  remains  a  part  of  it.  The  jacket  is  cut  out  to 
fit  under  the  arms,  and  the  edges  everywhere  pressed  away  from 
the  skin.  The  stockinet  may  be  turned  from  top  and  bottom  and 
sewn  together  in  the  middle  to  cover  the  plaster. 

The  spine  brace  is  of  many  varieties.  A  good  type  is  the  Taylor 
brace.  A  steel  band  with  its  center  at  the  spine  partly  encircles  the 
pelvis  below  the  iliac  crests  and  above  the  trochanters.  From  this 
pelvic  band  rise  two  uprights,  one  on  either  side  of  the  spinous 
processes,  resting  upon  the  transverse  processes,  and  extending  to  the 
tops  of  the  shoulders,  one  at  each  side.  The  uprights  are  connected 
by  a  horizontal  bar  just  below  the  angles  of  the  scapulae.  A 
leather  strap  or  webbing  or  a  padded  cord  extends  from  the  top  of 
each  upright  down  in  front  of  the  shoulder  of  the  same  side  to  the 
horizontal  bars.  There  are  many  modifications  of  this  brace.  The 
Taylor  brace  proper  has  a  leather  cuirass  or  apron,  covering  the 
belly  and  lower  part  of  the  thorax  and  held  to  the  metal  parts  at 
the  rear  by  straps  and  buckles.  The  brace  is  best  made  over  a  plaster 
model  prepared  by  casting  it  in  a  plaster  jacket  or  collar  as  the  case 
may  be,  put  on  the  patient  and  then  cut  and  sprung  off.  Or  it  may 
be  made  from  a  diagram  and  measurements.  The  child,  with  naked 
body  should  be  laid  prone.  A  few  touches  with  burnt  cork,  blue 
pencil,  solution  of  argyrol  or  bits  of  adhesive  plaster  will  mark  the 
points  for  measurement.  The  outline  of  the  spine  is  carefully  noted 
with  a  strip  of  lead  laid  on  and  bent  to  fit.  This  strip  of  lead  laid 
upon  paper  guides  a  pencil.  The  tapeline  finds  the  measurements  of 
every  part,  which  should  be  plainly  indicated  on  the  diagram. 

A  headpiece  can  be  attached  to  a  brace  or  to  a  jacket  by  in- 
corporating its  support  in  putting  on  the  jacket.  A  headpiece  con- 
sists of  a  steel  upright  or,  sometimes,  two  uprights,  extending  from 


446 


SURGICAL  DISEASES  OF  CHILDREN 


the  spine  brace  or  the  back  part  of  the  jacket  to  the  level  of  the 
base  of  the  skull.  From  the  upright  support  a  steel  band  extends 
forward,  and  being  properly  padded  supports  the  occiput  and  lower 
jaw.     (See  Fig.  159.) 

The  collar  is  made  of  plaster  of  Paris,  of  leather  with  steel 
reinforcements,  of  felt  leather-lined,  of  woven  wire  leather-lined. 
The  collar  spreads  out  upon  the  shoulders,  upper  part  of  the  back  and 
chest,  whence  it  takes  its  bearing,  and  is  fitted  to  the  base  of  the 
skull  and  lower  jaw  which  it  supports  and  renders  immovable.     (See 

Fig.  160  and  the  Calot  jacket,  Appendix 

36.) 

Head  extension  apparatus  has  a  padded 
sling  fitted  under  occiput  and  lower  jaw, 
with  the  patient  in  bed  or  upon  a  frame. 
The  sling  is  connected  with  cord,  pulley, 
and  weight,  to  make  extension  and  so 
fixation  of  the  cervical  spine.  The  vari- 
ous appliances  having  been  described,  it 
remains  to  state  the  principles  of  their 
action,  the  cases  to  which  each  is  applica- 
ble and  the  methods  of  their  use.  Sand- 
bags may  be  useful  in  recumbent  cases 
while  other  apparatus  is  being  made  or  in 
case  of  coexistent  skin  disease,  abscess  or 
glandular  swellings  or  pressure-sores 
which  interfere  with  the  use  of  fixed  ap- 
paratus. The  canvas-covered  frame  with 
the  light  steel  strips  at  the  margin  of  fenes- 
tration for  the  kyphosis  and  arched  with 
convexity  upward,  in  common  with  the 
brace,  has  some  action  as  a  lever 
The  fulcrum  being  upon  the  transverse 
processes,  at  the  seat  of  the  deformity, 
it  prevents  the  collapse  of  the  diseased  vertebral  bodies,  indeed 
limits  pressure  upon  them  by  compelling  the  carrying  of  weight 
or  receiving  pressure  upon  the  posterior  portions  of  the  col- 
umn, namely  the  transverse  and  spinous  processes.  They  act 
more  efficiently  by  immobilizing  the  diseased  tissues,  prevent- 
ing the  irritation  of  motion,  securing  rest.  It  is  often  taught 
that  the  jacket,  by  pressing  upon  the  body  at  every  point,  sustains 
it  upon  the  base-line  of  the  jacket,  namely  the  pelvis,  relieving  the 
diseased  vertebrse  of  weight,  provided  the  disease  is  within  the 
lower  portion  of  the  jacket,  that  is,  the  lumbar  region  or  the  dorsal 
region  below  the  seventh  dorsal  vertebra.     But  I  believe  that  by 


Fig.  158.    Washburne's 
BRACE  for  Pott's  disease. 


THE  SPINE 


447 


far  the  greatest  benefit  that  is  derived  from  the  jacket,  as  from  the 
frame,  brace,  or  extension  apparatus,  is  because  of  immobilization. 
Foundation  for  this  belief  is  found  in  the  fact  that  even  in  high 
dorsal  caries,  a  jacket  extending  up  the  back  and  front  of  the 
thorax  and  more  or  less  perfectly  immobilizing  the  spine,  far  above 
the  point  where  any  weightcarrying  could  be  possible,  w^ill  often  re- 
sult in  benefit.  This  explains  why  the  jurymast  with  sling  allow- 
ing head  rotation  has  been  discarded  for  an  apparatus  which  holds 
the  head  immovable.  It  is  in  cases  of  cervical  and  high  dorsal 
caries  that  head  support  and  head  extension  are  applied.  The  pul- 
ley and  weight  for  head  extension  are  used  only  for  a  short  time  in 
actively  progressing  cases  until  the  prog- 
ress of  the  disease  has  been  controlled, 
then  the  head  extension  or  support  is  re- 
lied upon  for  immobilization. 

That  form  of  apparatus  should  be  ap- 
plied which  maintains  the  diseased  parts 
as  nearly  as  possible  immovably  fixed  in 
their  normal  position  without  the  use  of 
violent  force  or  undue  pressure  at  any 
point.  The  horizontal  position  aids  in  se- 
curing rest  and  should  be  used  in  actively 
progressing  cases.  After  the  activity  of 
the  disease  process  has  been  controlled, 
the  upright  position  and  then  going  about 
with  jacket  or  brace  are  allowed.  Me- 
chanical treatment  will  probably  be  neces- 
sary for  from  two  to  five  years  or  possibly 
for  life,  unless  operative  treatment  shall 
prove  a  means  of  shortening  it.  The 
general  treatment  of  tuberculosis  as  laid 
down  in  Chapter  Iv.  is  indicated  in  all 
cases  of  spinal  caries. 

A  method  of  effecting  immobilization 
of  the  diseased  joints  in  Pott's  disease  by 
operation  has  been  devised  and  practised  by  R.  A.  Hibbs.^ 

The  operation  is  as  follows.  A  longitudinal  incision  is  made 
directly  over  the  spinous  processes  of  the  kyphosis  and  including  one 
sound  vertebra  above  and  one  below  those  diseased.  (If  the  X-ray 
does  not  reveal  the  extent  of  the  disease  one  must  be  guided  by  the 
kyphosis).  The  incision  goes  through  the  skin,  supraspinous  liga- 
ment and  periosteum  to  the  tips  of  the  spinous  processes.  The 
periosteum  is  divided  upon  both  the  upper  and  lower  borders  of 

^  Hibbs :   N.  Y.  Med.  Journ.,  May  27,   191 1;  Am.  Surg.,  May,  1912;  Jour. 
Am.  Med.  Assn.,  Aug.  10,  1912. 


Fig.  159.  Spinal  brace 
with  head  support,  sumilar 
to  Taylor's. 


448  SURGICAL  DISEASES  OF  CHILDREN 

each  spinous  process  and  the  laminae  are  stripped  from  them  out- 
ward to  the  bases  of  the  transverse  processes.  The  muscles  are  not 
detached  from  periosteum  and  ligament  but  the  flaps  are  pushed 
aside  en  masse.  Then,  beginning  with  the  lowermost,  each  spinous 
process  is  partly  cut  through  at  the  base  upon  its  upper  side  and 
bent  downward  so  that  its  tip  rests  upon  the  bone  next  below.     From 


Fig.  i6o.    Leather  collar  for  caries  of  cervical  spine. 

the  lower  edge  of  each  lamina  (bared  of  periosteum)  a  small  strip 
of  bone  is  raised  and  turned  downward  with  its  free  end  in  con- 
tact with  the  lamina  next  below.  The  flaps  consisting  of  perios- 
teum, split  supraspinous  ligament  and  muscle  are  brought  together 
and  sutured  over  the  prostrated  spinous  processes  with  interrupted 
sutures  of  chromic  gut,  and  the  skin  sutured  with  silk  or  plain  gut. 
Gauze  dressing  and  an  ordinary  spinal  brace  is  applied,  with  its  up- 
right bars  wide  enough  apart  not  to  press  upon  the  wound.  Rest 
in  bed  is  required  during  eight  to  ten  weeks;  then  sitting  up  is  al- 


THE  SPINE  449 

lowed  for  four  weeks.  After  twelve  weeks  walking  is  permitted. 
The  brace  is  laid  aside  after  another  month,  unless  the  patient  is 
under  five  years  of  age,  in  which  case  it  is  used  six  months.  The 
effect  sought  in  this  operation  is  the  deposition  of  new  bone  be- 
tween the  raised  periosteum  and  the  denuded  bone,  fusing  the 
vertebrae,  bridging  between  them  or  at  least  forming  a  bony  splint, 
thus  producing  fixation  and  consequent  rest.  In  seventeen  per  cent, 
of  Hibbs'  cases,  fusion  of  two  or  more  vertebrae  was  demonstrable 
and  curative  results  are  reported  in  practically  all  the  cases.  It  is 
probable  that  this  osseous  splint  would  form  even  if  there  were  no 
bone  grafts  raised  from  the  laminae  and  the  spinous  processes  were 
not  fractured  and  turned  downward.  But  this  latter  step  in  the 
technique  appears  to  strengthen  the  bridge,  and  it  certainly  lessens 
the  deformity,  especially  in  the  lower  dorsal  region.  The  operation 
has  been  used  in  patients  of  all  ages  from  two  and  one-half  years 
to  middle  life,  and  in  cases  that  have  run  from  three  months  to  ten 
years.  Hibbs  also  suggested  that  in  the  very  young  it  might  be 
necessary  to  graft  bone  from  the  leg.  This  has  since  been  done  by 
Albee,^  and  Whitman.- 

Albee  splits  the  spinous  processes  longitudinally,  bending  the 
lateral  halves  on  one  side  so  as  to  open  a  fissure  into  which  a  splint 
of  bone  (with  its  periosteum,  triangular  on  cross-section)  taken 
from  the  crest  of  the  tibia,  is  placed,  and  sewn  with  kangaroo  ten- 
don. If  necessary  to  meet  the  curve  of  the  kyphosis,  he  bends  the 
graft  with  or  without  notching  it.  He  keeps  the  patient  on  a  Brad- 
ford frame  from  six  to  ten  weeks.  Of  the  two  procedures  Hibbs' 
seems  more  reasonable.  Both  require  more  time  for  their  ultimate 
proving. 

Abscess  from  spinal  caries  is  to  be  treated  conservatively.  If 
it  point  and  need  for  evacuation  becomes  urgent  that  should  be 
done  by  aspiration  with  strict  antiseptic  precautions  and  the  punc- 
ture sealed.  Some  open  with  a  knife  and  inject  bismuth  paste. 
The  formulae  for  preparing  bismuth  paste  and  direction  for  its 
use  will  be  found  under  treatment  of  empyema.  Unless  the  infec- 
tion is  evidently  a  mixed  one,  it  is  probably  better  to  reserve  this 
procedure  for  abscesses  that  refill  and  for  chronic  sinuses. 

In  paralysis  from  Pott's  disease  the  treatment  is  conservative. 
Patient  and  persistent  rest  and  fixation  of  the  spine,  massage  and 
perhaps  electricity  to  the  lower  extremities,  together  with  the  gen- 
eral treatment  recommended  for  tuberculosis,  will  usually  restore  the 
lost  functions. 

lAlbee:  Jour.  Am.  Med.   Assn.,   Sept.  9,  1911,  p.  885;   N.  Y.  Med.  Jour., 
Mar.  9,  1912. 

''Whitman:  Am.  Surg.,  Dec,  191 1. 


CHAPTER  XVII 

SURGERY   OF   THE   AIR-PASSAGES 

Malformation  and  Other  Obstructions  of  Nasal  Passages — 
Falls  or  Blows  upon  the  Nose — Neoplasms  in  the  Nose — 
Hyperplasia  of  the  Lymph  Tissue  of  the  Pharynx  and 
Naso-Pharynx  —  Enlarged  Tonsils  —  The  Uvula  —  Ob- 
struction by  the  Soft  Palate — Foreign  Bodies  in  the 
Nose — Foreign  Body  in  the  Gullet — Tongue-Swallowing 
—  Retro-Pharyngeal,  or  Post-Pharyngeal  Abscess  — 
Chronic-Pharyngeal  Abscess. 

Disorders  of  the  air  passages  which  come  to  the  surgeon  for 
relief  are  usually  in  the  form  of  obstructions  to  the  free  passage  of 
air,  due  to  malformation,  edema,  hypertrophy,  new  growth,  foreign 
body,  or  inflammatory  exudate ;  although  troublesome  discharges 
may  be  the  cause  of  complaint,  or  altered  voice,  or  a  recent  trauma- 
tism, or  a  too  wide  opening  as  in  hare-lip  or  cleft  palate.  This  latter 
will  be  considered  under  a  separate  heading. 

Any  condition  which  interferes  with  the  free  and  abundant  respi- 
ratory flow  to  and  fro  through  the  natural  passages  is  a  serious 
menace  to  health  and  development.  No  one  not  familiar  with  infants 
would  be  willing  to  believe  that  even  a  simple  rhinitis  or  adenoids 
of  common  size  could  produce  the  severe  degree  of  discomfort,  rest- 
lessness, dyspnea,  interference  with  sucking,  and  disturbed  sleep 
which  experienced  pediatricians  know  as  ordinary  results. 

Ordinary  rhinitis,  acute,  chronic,  hypertrophic,  atrophic,  syphi- 
litic in  its  milder  forms,  or  tubercular,  seldom  come  to  the  surgeon 
for  the  partial  or  temporary  obstruction  produced,  being,  excepting 
the  last  named,  and  the  later  manifestations  of  syphilis,  amenable  to 
medical  treatment. 

MALFORMATION    AND    OTHER    OBSTRUCTIONS    OF    NASAL 

PASSAGES 

Congenital  atresia  of  the  nostrils,  absence  of  one  or  both  nos- 
trils, or  of  the  entire  nose,  may  occur. 

Permanent  obstruction  of  one  or  both  nostrils  may  occur  by 
malposition  of  the  cartilaginous  nasal  septum,  and  this  may  be  con- 
o-enital  or  acquired.  Or  the  vomer  or  the  ethmoid,  or  these  with  the 
cartilage  may  depart  from  the  normal  line,  and  cause  obstruction  in 

450 


SURGERY   OF   AIR    PASSAGES  451 

the  canal  of  the  nostril,  sometimes  in  the  form  of  a  wedge  or  ridge, 
and  often  with  a  corresponding  concavity  in  the  opposite  nostril. 

I\Ial formation  or  hypertrophy  of  the  turbinated  bones,  inferior, 
middle,  or  superior,  one  or  more,  may  encroach  upon  the  lumen  of 
the  nostril.  Hypertrophy  of  the  superior  is  more  rare,  that  of  the  mid- 
dle more  extensive  when  it  does  occur,  and  that  of  the  inferior  more 
common.  The  openings  of  the  nostrils  into  the  vault  of  the  pharjmx 
may  be  congenitally  abnormally  small  in  all  dimensions,  or  narrowed 
to  mere  slits,  or  may  be  entirely  occluded  by  encroachment  of  their 
bony  walls,  or  by  a  projection  formed  of  the  upper  cervical  vertebrse. 

Syphilitic  ulceration  may  result  in  collapse  of  the  bony  supports 
of  the  naso-pharynx,  and  obliteration  of  its  spaces.  (Figs.  27  and 
28.)  Repair  subsequent  to  ulceration  or  to  traumatism,  even  the 
traumatism  of  clumsy  surgery,  may  produce  synechiae — adhesions 
between  the  walls  of  the  nostrils,  notably  between  the  turbinated 
bones  and  the  septum. 

Treatment. — Any  of  these  conditions,  excepting  the  severe  mal- 
formations at  the  naso-pharynx,  may  be  treated  with  surgical  means 
appropriate  for  the  removal  of  the  obstruction  and  restoration  of  a 
freer  air  channel.  One  important  rule  in  these  operations  is  to  re- 
move as  little  as  possible  of  the  muco-periosteum  or  perichrondrium ; 
and  certainly  in  removing  "  spurs  "  or  deflections  of  the  septum  not 
to  leave  an  opening  through  into  the  other  nostril  as  is  sometimes 
done.  Deviations  of  the  septum  in  children  may  sometimes  be 
straightened  by  forcing  them  into  an  over-corrected  position — repeat- 
ing the  procedure  at  intervals  or  retaining  the  correction  by  stiff 
rubber  tubing.  In  removing  enlargements  of  the  turbinated  bones 
in  children  the  scissors  will  often  be  found  more  serviceable  than 
the  saw. 

FALLS  OR  BLOWS  UPON  THE  NOSE 

After  a  fall  upon  the  face  or  blow  upon  the  nose  a  careful  ex- 
amination should  be  made  to  determine  the  patency  of  the  nasal 
canals.  If  displacement  of  fragments  has  occurred  they  should 
be  lifted  into  place  by  an  instrument  passed  within,  and  can  gen- 
erally be  held  in  position  and  protected  by  small  pads  externally 
at  either  side  of  the  nose,  secured  by  adhesive  strips.  Rubber  tubing 
in  the  nostrils  can  be  used  to  maintain  patency,  but  is  seldom  neces- 
sary. A  dislocation  of  the  anterior  end  of  the  septum  nasi  from  the 
nasal  ridge  is  not  uncommon,  and  if  the  muco-periosteum  is  torn 
through,  may  prove  astonishingly  difficult  to  hold  in  place.  I  have 
sometimes  resorted  to  silver  wire  suture.  Abscess  of  the  septum 
may  occur  and  require  opening.  (See  also  Section  on  Fracture  of 
Nasal  Bones.) 


452  SURGICAL  DISEASES    OF   CHILDREN 

NEOPLASMS  IN  THE  NOSE 

Neoplasms  in  the  nose  other  than  adenoids  (which  see)  are 
not  common. 

Mucous  polypus  is  not  near  so  common  as  in  the  adult.  When 
brought  to  view  it  is  easily  recognized  by  its  luster,  its  translucency, 
and  its  paler  color  as  compared  with  the  mucous  membrane.  It  is 
apt  to  shift  out  of  sight.  It  feels  soft  to  the  probe  and  eludes  the 
instrument.  It  is  usually  pedunculated,  and  can  be  removed  with 
the  wire  snare.  When  one  is  removed  search  should  be  made  for 
others. 

Swollen  mucous  membrane  covering  a  crooked  septum  or,  more 
likely,  that  over  a  turbinated,  may  be  mistaken  for  polypus,  but 
should  be  distinguished  by  its  firmer  consistency  and  darker  color. 
Darker  color  as  well  as  absence  of  pedicle  should  distinguish  nevus 
which  may  occur  in  the  nares.  It  is  well  also  to  bear  in  mind  in  this 
connection  Mr.  Owen's  reference  to  the  case  of  Mr.  Bernard  Pitts, 
in  which  a  meningocele  projected  into  the  nares  and  was  even  by 
that  competent  surgeon  unfortunately  mistaken  for  a  polypus. 

Fibromata,  or  fibro-sarcomata,  while  rarely  if  ever  found  in  the 
naso-pharynx  in  infants  or  young  children,  are  not  very  uncommon 
after  the  tenth  year,  especially  in  boys.  They  may  usually  be  dis- 
tinguished by  touch  from  adenoids  and  are  generally  single  and  ses- 
sile. Fibromata  are  more  often  attached  to  the  sides  than  to  the 
vault  of  the  naso-pharynx.  They  give  symptoms  similar  to  those 
of  adenoids.  But  sarcoma  is  likely  to  be  painful  and  to  bleed 
spontaneously. 

The  prognosis,  even  in  fibroma,  if  not  removed  by  operation,  is 
quite  serious,  as  the  tumor  may  grow  to  immense  size,  with  cor-. 
responding  pressure,  distortion,  and  ulceration  of  the  surrounding 
structures.  If  sarcomatous  elements  are  present  in  the  growth, 
early  operation  affords  the  only  hope  of  averting  a  fatal  ending  in 
the  course  of  a  few  months  or  at  farthest  a  few  years,  probably  after 
frightful  deformity  and  great  suffering. 

Fibromata,  if  sufficiently  pedunculated,  may  be  removed  by 
the  galvano-cautery,  care  being  taken  to  thoroughly  remove  the 
whole  growth.  They  are  often,  if  small,  removed  with  the  ordinary 
snare,  and  the  stump  cauterized.  The  removal  of  a  large  fibroma 
or  sarcoma  from  the  posterior  nares  is  a  much  more  difficult  under- 
taking. It  may  be  attacked  through  the  mouth,  the  patient's  head 
being  inverted,  the  soft  palate  split  up,  and,  if  necessary,  a  part  of 
the  bony  palate  divided.  After  thorough  removal  of  the  growth, 
with  a  snare  if  possible,  the  base  is  to  be  thoroughly  cauterized  with 
galvanic  or  Paquelin  cautery,  and  the  palate  closed  as  in  staphy- 
loraphy. 


SURGERY   OF   AIR    PASSAGES  453 

Sarcoma  of  the  nose  can  be  removed  by  resection  of  the  superior 
maxillary  bone,  in  some  instances  leaving  the  orbital  plate. 

HYPERPLASIA    OF   THE    LYMPH    TISSUES    OF    THE 
PHARYNX  AND   NASO-PHARYNX 

The  lymphoid  tissue  at  the  base  of  the  tongue,  the  palatal  ton- 
sils, one  at  each  side  of  the  throat,  and  the  pharyngeal  tonsil  in  the 
naso-pharynx  forming  the  so-called  lymphoid  ring,  are  subject  to 
hyperplasia. 

Adenoids. — Enlargement  of  the  tonsils  has  long  been  dealt  with 
as  a  pathological  condition  of  some  importance.  Since  Meyer's 
v^^ork,  the  profession,  through  clinical  observations,  reports,  essays, 
and  discussions  on  every  hand,  has  become  more  or  less  familiar 
with  "  adenoids,"  "  adenoid  vegetations,"  "  hyperplasia  of  the 
pharyngeal  tonsil,"  "  post-nasal  growths." 

Lymphoid  tissue  in  ultimate  structure  resembling  the  lymphatic 
glands  and  the  Malpighian  corpuscles  of  the  spleen,  normally  under- 
goes an  involution  during  infancy,  childhood,  and  youth.  In  early 
life  the  pharyngeal  tonsil  presents  in  the  pharyngeal  vault  a  some- 
what furrowed  and  but  slightly  thickened  layer  of  lymphoid  tissue 
covered  with  ciliated  epithelium. 

When  hypertrophied  we  have  spongy  masses  or  nodules,  sessile 
or  pediculated,  structurally  papillomata  with  a  lymphoid  parenchyma 
and  a  very  vascular  mucous  and  epithelial  covering,  frequently  en- 
veloped with  mucus  or  mucopus. 

Opinions  differ  as  to  whether  deviated  septum,  hypertrophic 
rhinitis,  enlargements  of  the  turbinates  and  other  obstructions  favor 
the  growth  of  adenoids  or  are  instead  caused  by  the  adenoid  en- 
largement. 

We  sometimes  find  the  other  partial  obstructions  without  ade- 
noid vegetations  with  no  unusual  deviations  from  normal  develop- 
ment and  symmetry.  Numerous  discussions  have  been  indulged  in 
as  to  whether  repeated  colds  or  catat-rhs  produced  adenoids,  or 
whether  the  symptoms  attributed  to  the  cold  or  catarrh  were  not 
themselves  produced  by  the  pre-existing  adenoids.  However,  we 
know  that  victims  of  adenoid  growths  are  frequently  and  sometimes 
constantly  affected  with  what  passes  for  "  a  cold  in  the  head." 
Similarly  climate,  mechanical  irritation,  general  lymphatism,  race, 
sex,  scrofula,  or  tuberculosis  and  syphilis  have  entered  into  the  dis- 
cussion. Also  the  effects  of  measles,  scarlatina,  and  diphtheria  and 
whooping-cough,  typhoid  fever  and  heredity. 

Infants  may  be  born  with  adenoid  growths  or  they  may  come 
at  any  subsequent  time,  though  most  cases  come  to  the  surgeon's 
attention  in  childhood  up  to  the  eight  or  tenth  year.  In  late  years 
the  removal  of  adenoids  is  the  commonest  operation  performed  at 
the  nose  and  throat  dispensaries.    One  writer  (Lenox  Brown)  found 


4S4  SURGICAL  DISEASES    OF   CHILDREN 

adenoids  in  as  high  as  eighty-eight  per  cent,  of  all  naso-pharyngeal 
hospital  cases,  and  places  their  frequency,  as  compared  with  enlarged 
palatal  tonsils,  as  six  to  five.  Not  all  writers  place  the  percentage 
quite  so  high,  but  all  agree  on  their  extreme  frequency,  on  their 
greater  frequency  than  enlarged  palatal  tonsils ;  all  allege  that  not- 
withstanding all  that  has  been  said  and  written  to  enlighten  the 
profession  on  the  subject  that  they  are  still  often  overlooked;  that 
their  effects  are  very  deleterious,  and  that  their  removal  can  only 
be  effected  by  surgical  means  and  is  followed  by  most  gratifying 
results. 

Symptoms. — The  symptoms  and  effects  fairly  attributable  in 
whole  or  in  part  to  postnasal  vegetations  are  obstructed  breathing, 
mucous  or  muco-purulent  discharge  from  nostrils  or  into  pharynx, 
altered  speech,  mouth-breathing,  snoring,  disturbed  sleep,  difficult 
suckling  in  infants,  partial  deafness,  catarrh  of  Eustachian  tube, 
otitis  media  catarrhal  and  suppurative,  deficient  oxygenation  of  the 
blood,  alterations  of  the  contour  of  the  face,  deformities  of  the 
chest,  impaired  cerebral  circulation  and  consequently  development, 
loss  of  memory,  stunted  growth,  croup  and  laryngismus,  asthma, 
stammering ( ?),  local  or  general  convulsions,  torticollis,  altered 
voice  and  articulation,  deaf-mutism,  irritable  pharynx,  capricious 
appetite,  palpitation  of  the  heart,  drowsiness,  sullen  disposition,  re- 
tarded dentition,  retarded  puberty,  high  arching  of  the  palate  with 
narrowing  of  the  nostrils — certainly  a  formidable  indictment  with 
many  counts.  Not  "that  all  these  signs  and  symptoms  are  present 
in  all  cases  or  in  any  one  case.  Any  one  or  all  of  them  may  be  absent 
and  yet  adenoids  present.  Even  mouth-breathing  and  snoring  may 
be  lacking,  or  the  patient  may  be  able  to  breath  freely  with  the 
mouth  and  either  nostril  held  shut. 

The  alterations  in  the  facial  appearance  of  a  case  of  long  stand- 
ing are — a  dull  vacant  look  with  mouth  open  and  staring  eyes,  the 
nostrils  narrow,  the  bridge  of  the  nose  wide,  the  eyes  seeming  wide 
apart,  and  the  jaws  enlongated  and  flattened  over  the  malar  bones. 
The  palate  is  high  and  narrow,  and  the  dental  arch  too  small  to  ac- 
commodate the  teeth,  which  crowd  and  overlap. 

The  type  of  thorax  is  that  commonly  called  "  hollow-chested 
and  stoop-shouldered."  Its  antero-posterior  measurement  is  small. 
The  angles  of  the  scapulae  point  backward  and  the  clavicles  are 
very  much  S-curved,  thus  bringing  the  shoulder  joints  prominently 
forward  and  approximating  them  across  the  narrow  upper  thorax. 
The  sternum  is  often  lowered  with  relation  to  the  vertebrae  and  the 
upper  dorsal  and  cervical  spine  curved  forward.  The  ribs  droop 
suddenly  from  their  attachments  to  the  spinal  column,  nearly  oblit- 
erating the  intercostal  spaces  posterially,  but  curving  upward  to 
the  sternum  the  spaces  are  widened  in  front. 


SURGERY   OF  AIR   PASSAGES 


455 


The  typical  face  and  thorax  of  the  victim  of  adenoids  are  well 
shown  in  Figs.  i6i  and  162. 

Diagnosis. — The  diagnosis  can  be  made  almost  to  a  certainty 


Fig.  161.  Showing  the  effects 
upon  the  face  and  figure  of 
obstruction   of   the   upper   air 

PASSAGES      BY      HYPERTROPHY      of 

the     lymphoid     tissues     of     the 
naso-pharynx. 


Fig.  162.  Effects  of  adenoids 
AND  enlarged  TONSILS.  Same 
as  Fig.  161.  Back  view.  Dorsal 
and  cervical  spine  curved  for- 
ward. Lower  angles  of  scapulae 
point  backward. 


by  inspection  of  the  patient,  the  evidence  being  corroborated  by  an 
account  of  the  symptoms.  In  some  children  the  growths  can  be 
seen  through  the  nostrils  or  with  the  throat  mirror.  Diagnosis  is 
easily  verified  by  a  digital  exploration  of  the  pharyngeal  vault.    In 


456  SURGICAL   DISEASES    OF   CHILDREN 

daily  work,  digital  exploration  is  so  much  more  satisfactory  and 
rapid  that  it  is  usually  relied  upon.  The  surgeon's  right  index  fin- 
ger, with  palmar  surface  upward,  is  passed  behind  the  velum  palati, 
and  in  two  or  three  seconds'  time  has  explored  the  vault  and  pos- 
terior nasal  openings. 

Treatment. — The  only  treatment  of  adenoids  that  can  be  advised 
as  satisfactory  is  their  clean  removal,  with  some  form  of  edge-tool. 
Immediately  the  question  arises,  "If  operated,  will  they  return?" 
The  answer  is,  "  As  a  rule,  when  carefully  removed,  they  do  not 
recur.  But  if  they  did  recur  within  a  year  or  in  a  half  year,  it 
would  still  be  better  to  remove  them."  It  is  not  advisable  to  operate 
for  adenoids  in  the  presence  of  diphtheria,  scarlet  fever,  measles  or 
other  acute  illness.  Treatment  of  adenoids  by  internal  medicines  is 
useless.  It  is  true  that  many  patients  with  adenoids  stand  in  need 
of  tonic  and  alternative  medication.  Syrup  of  the  iodide  of  iron, 
or  other  ferruginous  preparation,  cod-liver  oil,  hypophosphites,  malt 
and  other  reconstructive  agents,  though  they  have  no  effect  on  the 
growths,  are  useful  to  such  patients  in  a  general  way;  but  they 
produce  a  much  greater  benefit  if  his  air  passage  is  first  cleared  so 
that  he  can  secure  an  unstinted  supply  of  oxygen.  Local  applica- 
tion of  astringents  or  antiseptics  to  the  growths  may,  if  persisted 
in,  produce  improvement  in  the  symptoms,  but  are  slow,  tedious, 
and  unsatisfactory  as  compared  with  instrumental  ablation,  and  are 
not  without  danger  to  the  Eustachian  tube  and  middle  ear.  The 
use  of  caustics  upon  the  growths  is  difficult  if  thoroughly  done, 
inefficient  if  not  thoroughly  done,  and  is  a  clumsy  and  dangerous 
procedure  by  comparison.  Scarifying  and  crushing  the  growths 
have  also  been  advocated  and  may  dispose  of  the  obstruction.  These 
methods  have  nothing  to  recommend  them  over  a  clean  removal. 
There  can  certainly  be  no  advantage  in  leaving  shredded  or  com- 
pressed and  bruised  investments  of  the  growths  hanging  to  the 
vault  of  the  pharynx. 

The  snare  might  serve  for  removing  one  or  two  pediculated 
vegetations.  But  where,  as  usual,  there  is  a  sessile  mass,  there  are 
other  instruments  more  serviceable.  Various  instruments  have  been 
devised  for  the  removal  of  adenoids,  and  many  modifications  of  the 
various  types,  to  suit  the  ideas  of  many  different  operators.  For 
example,  the  ring  knife,  the  metal  fingernail,  the  cutting  forceps 
(small  and  nearly  straight,  for  use  through  the  nose,  larger  and 
curved  for  use  through  the  month),  the  curette,  the  curved  scissors, 
the  sharp  spoon,  the  adenotome  and  others.  Some  operators 
prefer  to  work  through  the  nostrils.  To  me  that  seems  like  crawl- 
ing in  through  a  small  window  when  one  might  walk  in  through 
an  open  door.  Some  operators  prefer  to  have  the  patient  in  an 
upright  position ;  others  want  him  recumbent ;  and,  if  recumbent. 


SURGERY   OF   AIR   PASSAGES 


457 


one  hangs  his  head  over  the  end  of  the  table,  while  another  prefers 
to  lower  it  slightly.  Some  do  not  use  an  anesthetic,  so  that  the 
patient  may  sit  upright.  Some  administer  the  anesthetic  and  then 
place  the  patient  upright,  strapped  to  the  back  of  an  operating  chair, 


Fig.      164.       Kirstein's 
adenoid  curette. 


Fig     163.      Gottstein's    adenoid    curettes. 

his  head  held  by  an  as- 
sistant. Deaths  have  been 
reported  in  both  posi- 
tions. If  an  anesthetic 
is  to  be  used,   I  would 

rather  take  the  chances  with  the  patient  recum- 
bent and  his  head  lowered  sufficiently  over  the 
end  of  the  table  so  that  the  blood  will  not  readily 
run  into  the  larynx,  and  his  face  turned  suffi- 
ciently to  one  side  so  that  the  blood  can  readily 
run  out  of  his  mouth  or  be  swabbed  out. 

I  prefer,  if  the  child  be  docile  and  his  confi- 
dence has  been  secured  by  a  few  previous  pain- 
less examinations  or  treatments,  to  dispense  with 
the  anesthetic  and  operate  with  the  patient  sit- 
ting, using  a  sharp  Kirstein  curette  or  the 
cutting  forceps  of  Deible.  Some  surgeons 
prefer  a  Cradle's  guillotine,  which  has  a  fenestrum  and  a  knife 
like  a  tonsilotome,  but  is  curved  upward  to  fit  the  post-nasal 
space.  If  the  post-nasal  space  is  small,  or  the  growths  numer- 
ous or  broadly  sessile,  my  choice  of  instruments  is  the  curette. 
(See  Figs.  163,  164  and  165.)  Occasionally  the  spoon  forceps  is  a 
necessity,  or  the  double-edged  ring  knife.  I  use  Dalby's  metal  fin- 
ger-nail but  very  seldom  of  late.  The  bare  finger-nail  makes  a 
ragged  surface.  In  young  infants  a  uterine  curette,  bent  to  the 
proper  angle,  may  suffice.  From  habit  I  have  used  chloroform,  if 
any  anesthetic,  as  less  irritable  to  the  respiratory  tract ;  but  ether 
can  be  used  with  satisfaction,  and  is  probably  safer,  especially  in 


Fig.  165. 
Doyen's   forceps. 


458  SURGICAL  DISEASES    OF   CHILDREN 

these  cases,  which  may  be  associated  with  lymphatism.  Cocaine  is 
useful  in  older  children  in  a  2  per  cent,  solution.  General  anes- 
thesia by  ethyl-chloride  or  nitrous  oxide  may  be  used.  Whatever 
general  anesthetic  is  employed,  very  little  of  it  should  be  used.  The 
reflexes  are  never  abolished.  The  patient  can  always  cough  and 
clear  his  throat.  An  assistant  should  hold  his  hands.  When  enough 
anesthetic  has  been  given — probably  just  as  the  pupils  begin  to 
contract — the  head  is  drawn  over  the  end  of  the  table  and  lowered, 
a  gag  placed  between  the  teeth,  and  the  mouth  opened.  The  head 
and  gag  are  held  by  an  assistant — the  anesthetizer  if  no  other  is  to 
be  had.  If  enlarged  tonsils  are  to  be  removed,  it  is  better  to  do  that 
before  the  adenoids,  taking  first  the  tonsil  less  easy  to  seize  in  the 
tonsilotome,  for  later  the  blood  obscures  the  field.  After  the  ton- 
sils come  the  adenoids,  in  rapid  succession,  unless  one  should  en- 
counter dangerous  bleeding,  which,  in  rare  cases,  may  occur.  (See 
Tonsilotomy.) 

The  adenoid  operation  is  all  by  touch.  It  is  convenient  to  have 
a  dozen  or  more  swabs  of  absorbent  cotton,  well  wound,  on  the 
end  of  small  sticks.  I  find  butchers'  skewers,  six  inches  long,  con- 
venient for  making  these  stick  sponges.  Hemorrhage  is  sharp  for 
a  minute,  but  generally  ceases  spontaneously. 

Practically  no  after-treatment  is  necessary  except  that  after  any 
anesthesia.  Some  patients  complain  of  severe  headache  on  first 
recovering  consciousness,  but  this  gradually  subsides.  Vomiting 
of  blood  swallowed  is  apt  to  ensue.  The  child  should  remain  in  the 
house  for  some  days  in  the  cold  season.  Dust  is  to  be  avoided. 
There  is  generally  no  traumatic  fever.  Sprays  and  douches  are  not 
advised.  Secondary  hemorrhage  may  occur,  but  need  not  occasion 
alarm.  Otitis  media  or  pneumonia  are  possible  sequellge,  thought 
to  be  caused  by  blood  running  into  Eustachian  tube  or  into  lungs. 
The  latter,  at  least,  should  be  avoided  by  proper  position  of  the 
patient.  Most  patients  experience  marked  beneficial  results  very 
promptly  after  operation,  as  evidenced  by  improved  general  vigor, 
growth,  and  development.  Some,  particularly  the  younger  ones 
and  cases  not  of  long  standing,  recover  nose-breathing  and  natural 
intonation  almost  at  once.  Others,  usually  older  children  and  older 
cases,  may  need  training  to  break  the  confirmed  habit  of  mouth- 
breathing,  either  while  awake  or  asleep.  A  chin  support,  with  a  piece 
to  cover  the  mouth,  to  be  held  in  place  with  straps  over  the  head,  to 
be  worn  at  night,  may  help.  Or  adhesive  strips  across  the  mouth 
may  have  a  good  physical  or  moral  effect.  Such  cases  often  need, 
also,  corrective  gymnastics,  particularly  the  "  setting-up  "  exercises 
and  breathing  exercises  for  their  undeveloped  lungs,  flat  chests,  and 
rounded,  drooping  shoulders. 


SURGERY   OF   AIR   PASSAGES  459 

ENLARGED  TONSILS 

A  strict  classification  would  place  enlarged  tonsils  with  dis- 
eases of  the  pharynx,  but  the  practical  importance  of  this  very- 
common  ailment  depends  on  the  obstruction  to  the  air  passage  occa- 
sioned thereby,  and  it  is  convenient  to  consider  it  in  this  connection. 

There  is  no  disease  or  condition,  unless  it  be  adenoids,  which 
more  frequently  requires  the  services  of  the  child's  surgeon  than 
enlarged  tonsils. 

They  may  be  present  congenitally,  though  this  is  rare.  Nor 
are  they  so  very  commonly  met  with  in  infancy.  But  after  the 
period  of  infancy  they  seem  more  frequent,  and  through  childhood 
and  early  youth  occur  in  greatest  numbers,  decreasing  toward  pu- 
berty. At  least  it  is  true  that  the  patient  suffers  less  from  the  ail- 
ment as  the  development  of  that  period  increases  the  capacity  of  the 
throat.  It  appears,  top,  that  in  the  hyperplastic  form,  shrinking 
takes  place  in  the  enlargement  as  age  advances,  through  contrac- 
tion of  connective  tissue. 

Bosworth  describes  two  distinct  forms  of  enlarged  tonsils. 
First,  the  hypertrophic  form,  in  which  the  lymphoid  tissue  is  in- 
creased in  quantity,  with  a  comparatively  slight  increase  of  the 
stroma  of  the  gland,  and  an  increased  vascular  supply.  This  pro- 
duces an  enlargement  irregular  upon  the  surface,  with  large  crypts, 
deeper  red  in  color,  more  spongy  to  the  touch.  In  the  second,  or 
hyperplastic  form,  the  increase  is  in  the  connective  tissue  stroma  ;  the 
crypts  are  not  in  evidence ;  the  enlargement  is  smooth  and  rounded, 
paler  in  color  and  firmer.  While  these  two  types  are  met,  it  is  the 
experience  of  every  practitioner  that  they  are  apt  to  be  combined 
and  cannot  always  be  so  distinctly  differentiated.  One  or  both 
tonsils  may  be  affected.  In  general  shape  and  dimensions  the  en- 
larged organs  vary  greatly,  being  regular  or  irregular  in  outline  and 
projecting  slightly  toward  the  median  line  or  meeting  the  opposite 
tonsil  or  extending  downward  or  upward  or  in  all  directions.  Or 
the  enlarged  tonsil  may  be  attached  to  the  margins  of  the  faucial 
pillars  and,  instead  of  projecting  beyond  them,  carry  the  pillars 
with  it  in  its  distension.  There  may  or  may  not  be  in  the  same  case 
enlargement  of  other  portions  of  the  lymphoid  ring — notably  the 
pharyngeal  tonsil — much  less  frequently  the  lymphoid  tissue  at  the 
base  of  the  tongue.  In  regard  to  etiology,  it  is  not  always  possible 
to  decide  that  this  case  or  this  type  of  case  comes  by  heredity  while 
another  is  produced  by  irritation,  and  another  by  the  strumous 
diathesis.  Hereditary  predisposition,  repeated  irritations,  recurrent 
inflammations,  struma,  the  rheumatic  or  the  lymphatic  diathesis, 
digestive  disturbances,  rickets,  diphtheria,  scarlatina,  dentition ;  bad 
hygienic  environment,  such  as  dampness,  lack  of  fresh  air  and  sun- 
light, foul  gases,  re-breathed  air  of  closet-like  sleeping  rooms,  lack 


46o  SURGICAL  DISEASES    OF   CHILDREN 

of  proper  food  or  over-feeding,  bad  feeding  generally,  syphilitic 
taint,  are  all  apparent  causes,  predisposing  or  exciting,  of  enlarged 
tonsils,  although  we  find  cases  in  which  none  of  them  can  be  detected 
as  having  any  connection.  In  most  cases  more  than  one  possible 
causative  factor  can  be  discovered. 

Symptoms. — Enlarged  tonsils  of  moderate  degree  will  some- 
times be  discovered  during  routine  examinations  or  by  accident, 
when  there  were  no  symptoms  or  appearances  arousing  suspicion 
of  their  presence.  But  as  a  rule  their  results,  or  at  least  their  ac- 
companying symptoms  and  signs,  are  many  and  marked,  and  include 
all  those  enumerated  as  belonging  to  post-nasal  adenoids  (which 
see),  whether  affecting  respiration,  the  mouth-breathing  and  the 
nightmare,  speech,  hearing,  deafness  or  tinnitus,  secretion,  impair- 
ment of  smell  and  taste,  deformities  of  nose,  face,  thorax,  the  re- 
flexes, cough  and  laryngismus,  or  general  condition ;  and  add  to  these 
dysphagia,  foul  breath,  greater  impairment  of  intonation  and  more 
frequent  implication  of  adjacent  lymphatic  glands  at  the  angle  of  the 
jaw.  Of  late  years  the  tendency  of  writers  has  been  to  place  less 
stress  upon  enlarged  tonsils  as  causative  of  this  formidable  array  of 
symptoms,  and  more  upon  the  adenoids.  But  there  can  be  no  doubt 
that  either  is  capable  of  producing  them,  and  that  they  often  co- 
exist, the  adenoid  being  more  likely  of  the  two  conditions  to  escape 
detection. 

Prognosis. — The  probabilities  are  that  no  spontaneous  improve- 
ment of  chronically  enlarged  tonsils  will  take  place  before  puberty, 
and  that  even  then  the  condition  will  not  be  entirely  abated.  In  the 
meantime  the  child,  besides  suffering  many  symptoms  distressing 
to  itself  and  annoying  to  others,  will  be  seriously  impaired  in  its 
general  health  and  experience  deleterious  results  in  ill-developed 
nostrils  and  dental  arches,  crowded  and  overlapping  teeth,  in  mal- 
conformation  of.  face  and  figure,  and  in  use  of  lungs  and  voice,  not 
to  be  eradicated  for  the  remainder  of  its  life.  Also,  in  the  mean- 
time, as  with  adenoids,  if  attacked  by  diphtheria  or  scarlatina  or 
by  any  throat  or  lung  affection,  to  which  its  liability  is  increased, 
danger  is  appreciably  augmented. 

Diagnosis. — The  diagnosis  presents  few  difficulties.  The  swell- 
mg  of  acute  inflammation  can  be  readily  excluded  by  the  absence 
of  the  febrile  disturbances  and  tenderness,  the  redness  and  altered 
secretion  of  the  acute  condition.  But  a  chronically  enlarged  ton- 
sil may  be  acutely  inflamed  or  its  crypts  filled  with  a  collection  of 
cheesy  or  cretaceous  material,  perhaps  foul  smefling  and  irritating. 

A  peritonsilar  abscess  may  push  a  tonsil  into  prominence,  giv- 
ing it  the  appearance  of  enlarged  tonsil  adherent  to  the  pillars. 

Postpharyngeal  abscess  may  simulate  it  somewhat,  arid  is  not 
always  in  the  median  line  or  on  both  sides,  as  some  writers  state, 


SURGERY   OF   AIR    PASSAGES  461 

and  does  not  always  tend  to  point  anywhere  in  sight.  However,  the 
abscess  can  generally  be  distinguished  by  greater  difficulty  and 
especially  pain  on  swallowing,  by  diffused,  if  not  prominent,  swell- 
ing, by  touch,  and  perhaps  by  rigidity  of  the  neck  and  deep  swelling 
perceptible  behind  the  angle  of  the  jaw. 

Ashby  and  Wright  describe  the  occasional  appearance  of  "  a 
large  yellow  mass  .  .  .  blocking  up  the  whole  of  that  side  of 
the  pharynx.  It  is  soft  and  fluctuating,  and  on  incision  gives  exit 
to  a  large  quantity  of  thick  debris  of  mucus,  pus,  cholesterine,  etc. 
This  condition  we  have  sometimes  thought  to  be  a  congenital 
mucoid  cyst." 

The  possibility  of  neoplasms  of  the  tonsil  is  to  be  borne  in  mind. 

Treatment. — Treatment  is  demanded  by  the  presence  of  the 
enlarged  tonsil,  together  with  any  of  the  symptoms  attributed  to 
this  condition.  The  treatment  is  either  constitutional  or  local.  A 
discussion  of  the  constitutional  treatment  would  repeat  all  that  has 
been  said  on  that  topic  in  the  treatment  of  adenoids.  The  usual 
medical  treatment  of  enlarged  tonsils  is  the  treatment  of  accom- 
panying conditions,  such  as  disordered  stomach  and  bowels,  rickets, 
rheumatism,  colds  and  catarrhs.  There  is  no  remedy  with  specific 
virtues  for  this  condition.  It  is  possible  that  medication,  general 
and  local,  may  affect  hyperplastic  conditions,  but  the  hypertrophic 
remain  slightly,  if  at  all,  influenced.  In  all  cases,  good  nourishing 
diet,  warm  clothing,  dry  feet,  fresh  air,  preferably  by  the  sea  or  in 
the  country,  and  sunshine  are  to  be  recommended.  Such  drugs  as 
iodide  of  iron,  glycerophosphites,  phosphorus,  cod-liver  oil,  lacto- 
phosphate  of  lime,  guiacum,  salicylates,  and  alkalies  are  to  be  con- 
sidered. Taken  alone — that  is,  without  operation — medical  treat- 
ment of  enlarged  tonsils  is  notoriously  unsatisfactory. 

Local  treatment  is  either  palliative  or  radical.  Appropriate 
palliative  treatment  is  such  as  that  stated  by  D'Arcy  Power,  as  fol- 
lows :  "  Astringents  should  be  employed  where  there  is  reason  to 
suspect  that  the  enlargement  is  due  to  chronic  irritation,  rather  than 
to  true  hypertrophy.  The  astringents  I  have  been  accustomed  to 
use  are  glycerine  and  tannic  acid,  a  solution  of  nitrate  of  silver,  four 
grains  to  the  ounce,  or  the  solution  of  sulphate  of  zinc,  containing 
a  drachm  to  the  ounce.  These  solutions  are  painted  over  the  tonsil 
night  and  morning  by  means  of  a  camel's-hair  brush  in  a  handle." 

Other  agents  may  be  used,  as  compound  tincture  of  iodine. 
Some  use  alum  or  tannin,  or  both  together,  in  powder  form  or  in 
glycerine.  Tincture  of  the  chloride  of  iron,  one  or  two  drachms  in 
the  ounce  of  glycerine,  is  recommended  by  Beverly  Robinson. 
Adrenalin  chloride  is  a  newer  remedy. 

These  seem  to  me  to  represent  the  limit  of  the  useful  milder 
means  of  dealing  with  this  condition.     And  it  is  only  in  a  selected 


462  SURGICAL  DISEASES  OF  CHILDREN 

number  of  cases  that  these  are  useful.  In  the  majority  they  will 
be  found  powerless.  Among  them  all  the  compound  iodine  and  the 
tannin  and  alum  are  the  most  useful,  without  harming  the  teeth 
or  leaving  the  parts  feeling  stiffened  and  uncomfortable. 

Some  advise  the  use  of  much  stronger  solutions  of  silver  nitrate, 
ten  or  twenty  grains  to  the  ounce ;  or  the  solid  stick,  or  perchloride 
of  iron,  or  chromic  acid,  or  the  galvano  cautery  or  intra-paren- 
chymatous  injections  of  acetic  acid  or  carbolic  acid. 

These  I  do  not  employ  and  cannot  understand  the  logic  by 
which  Robinson  criticises  Cohen's  suggestion  of  electrolysis  because 
of  the  doubt  that  "  one  child  in  a  hundred  would  permit  the  con- 
tinued introduction  of  needles  into  the  tonsils,"  while  he  advocates 
the  use  of  the  galvano  cautery  and  chromic  acid,  described  as  fol- 
lows :  "  If  the  tonsils  be  scarified  in  two  or  three  places  with  the 
cautery,  the  useful  result  of  these  transcurrent  cauterizations  can 
be  increased  by  the  application,  on  these  burned  surfaces,  of  a  sat- 
urated solution  of  chromic  acid,  applied  by  means  of  a  flattened  or 
round  metallic  probe,  roughened  at  its  point."  I  quite  agree  with 
Ashby  and  Wright  when  they  remark  that  "The  only  efficient 
mode  of  treatment  is  by  removal ;  caustics  and  the  actual  cautery 
are  inferior  methods  of  obtaining  the  same  results,"  and  with 
Edmund  Owen,  who  says :  "  Other  ways  of  dealing  with  the 
hypertrophied  tonsils  have  been  suggested,  such  as  electrolysis  and 
puncture  with  the  blade  of  the  thermo-cautery.  Of  the  former  I 
have  no  experience,  nor  do  I  desire  it.  The  igni-puncture  I  have 
once  tried,  but  then  I  made  a  permanent  passage  through  the  ton- 
sil of  the  caliber  of  a  slate  pencil,  and  there  it  remained  until, 
some  months  afterward,  the  rigid  mass  was  amputated.  When 
once  it  has  been  decided  that  removal  of  the  tonsils  shall  be  under- 
taken, the  more  quickly  and  effectually  the  operation  is  accom- 
plished the  better." 

No  sooner  is  operation  proposed  than  one  is  met  by  the  popular 
notion  that  removal  of  the  tonsils  will  injure  the  voice.  But  voice 
and  speech  have  already  been  injured  by  the  disease,  and  one  assures 
the  parents  and  friends  of  the  child  that  operation  will  result  in 
benefit  only,  to  the  vocal  apparatus.  Injury  could  only  follow  if  ex- 
tensive scar  tissue  result.  Next,  one  meets  the  superstition  that 
operation  on  the  tonsils  damages  the  sexuality  of  the  individual, 
which  fallacy  one  can  deny  as  unfounded  in  fact.  Finally,  it  is 
objected  that  the  enlarged  tonsil  will  grov/  again  after  operation.  To 
this  is  answered  that  regrowth  of  the  tonsils  after  amputation  seldom 
occurs,  and  that  after  complete  tonsillectomy  it  cannot  occur. 
Operation  is  not  advisable  during  an  attack  of  inflammation ;  nor  if 
scarlatina  or  diphtheria  is  prevailing  in  the  home  or  immediate 
neighborhood. 


SURGERY  OF  AIR  PASSAGES  463 

Preparation  for  operation  is  useful,  especially  if  there  exists  a 
purulent  catarrh  of  the  nasopharynx.  Swabbing  with  solution 
of  argyrol  in  water  (10  per  cent.)  daily,  will  improve  the  con- 
dition. Ferruginous  tonics  are  in  order.  In  children  of  hemophil- 
iac tendencies  calcium  chloride,  gallic  acid,  gelatine  or  blood  serum 
may  be  used  beforehand.  Operative  treatment  consists  in  ton- 
sillectomy  or  tonsillotomy. 

Tonsillectomy  has  in  recent  years  gained  great  favor,  in  that  it 
more  thoroughly  removes  diseased  gland  tissue  and  prevents  not 
only  recurrence  of  the  enlargement  but  repeated  local  inflammations 
and  more  remote  affections  caused  by  absorption  of  infectious 
material  from  the  diseased  tonsils.  It  is  a  more  serious  operation 
than  tonsillotomy  and  is  usually  done  under  general  anesthesia  in 
children.  The  position  is  dorsal,  with  the  head  drawn  over  the  end 
of  the  table  and  turned  to  one  side  toward  the  light.  Good  light  is 
necessary.  Then  the  anesthetic  is  laid  aside.  The  gag  being  placed, 
a  tonsil  is  seized  with  volsellum  forceps  and  the  margins  of  the 
pillars  separated  from  it.  This  is  conveniently  done  by  Tyding's 
tonsil  knife  or  similar  slender  blade.  But  a  pair  of  sharp-pointed 
scissors  curved  on  the  flat  and  used  closed,  or  a  dissector  can  be 
used.  The  tip  of  the  index  finger  is  introduced  and  working  from 
above  downwards  the  tonsil  with  its  capsule  is  separated  from  its  at- 
tachments, all  but  that  portion  including  the  vessels  at  its  base. 
During  this  rapid  dissection,  care  should  be  taken  not  to  pull  strongly 
upon  the  volsellum  which  is  used  to  steady  the  organ  rather  than 
to  make  traction.  The  loop  of  a  strong  wire  snare  is  now  slipped 
over  the  volsellum  and  on  down  over  the  tonsil  to  its  pedicle,  which 
is  severed  at  one  motion  of  the  hand,  taking  care  not  to  drag  upon 
the  instrument,  in  so  doing.  If  both  tonsils  are  to  be  removed,  it  is 
most  convenient  to  operate  first  upon  the  tonsil  on  the  side  toward 
which  the  face  is  turned,  as  it  is  lowermost  and  the  blood  does  not 
so  much  obscure  the  field.  The  second  tonsil  is  now  removed  in 
the  same  manner.  If  adenoids  are  to  be  removed  this  is  done  last. 
Pressure  with  stick  sponges  for  a  few  moments  usually  controls  the 
hemorrhage,  but  spurting  vessels  may  have  to  be  seized  with  hemo- 
stats  and  sometimes  even  ligatured.  The  aftertreatment  is  similar 
to  that  for  tonsillotomy  at  the  end  of  this  Section.  Children  usually 
manifest  little  inconvenience  after  the  first  day  or  two. 

Tonsillotomy  (at  present  out  of  fashion)  consists  in  removal 
of  a  part  of  the  tonsil,  generally  as  much  as  projects  beyond  the 
pillars,  or  even  more,  by  means  of  knife,  scissors,  tonsillotome,  or 
cutting  forceps,  cold  wire  snare  or  galvano-cautery.  If  special  in- 
strument is  not  at  hand  the  work  can  be  done  by  seizing  the  tonsil 
with  a  volsellum  and  cutting  upward  with  blunt-pointed  bistouri. 
Tonsillotomes  are  in  many  patterns.     Some  have  a  prong  or  fork 


464  SURGICAL   DISEASES    OF   CHILDREN 

attached,  designed  to  pierce  the  projecting  portion  of  the  tonsil  and 
draw  it  through  the  ring  and  hold  it  transfixed,  or  to  seize  it  when 
severed.  My  own  preference  and  that  of  most  operators  at  present 
is  the  simpler  instrument  with  fewer  parts,  without  the  prongs  or 
fork.  It  is  less  apt  to  get  out  of  order  and  is  more  easily  cleaned. 
Besides,  the  transfixing  mechanism  might,  if  it  worked  at  all,  draw 


Fig.  166.     McKenzie's  Plain 
tonsillotome. 


an  uncertain  amount  of  the  tonsil  under  the  blade.    (See  Figs.  166 
and  167.) 

Some  operators  provide  two  tonsillotomes  in  readiness,  so  that 
in  removing  one  tonsil  after  the  other  in  rapid  succession,  no  time 


-  Fig.    167.     Bagin sky's   Plain  Tonsillotome. 

is  lost  in  disengaging  the  severed  portion  of  the  first  from  the 
instrument.  A  tonsil  may  be  so  ragged  and  so  friable  that  the  most 
serviceable  instrument  is  a  sharp  spoon  or  the  spoon  forceps. 

The  cold-wire  snare,  or  ecraseur,  or  the  galvanic  loop,  are  pre- 
ferred in  cases  of  extremely  large,  dense,  fibrous  tonsils,  or  in  a 
child  of  hemophiliac  tendencies,  or  who  is  markedly  anemic  and 
weak.  It  is  a  mistake  to  select  too  slight  an  instrument  of  the  snare 
variety.  The  cold-wire  apparatus  is  much  simpler,  more  easily 
managed,  and  more  certain  in  its  operation.  It  is  placed  where  the 
division  of  tissues  is  wished.  In  placing  the  galvanic  wire,  it  must 
be  remembered  that  the  tissues  will  be  charred  somewhat  deeper 
than  the  track  of  the  wire.  The  wire  should  be  heated  only  to  a 
dull  red,  and  that  intermittently,  and  tension  made  only  while  the 


SURGERY   OF   AIR    PASSAGES  465 

iron  is  hot.    With  either  the  cold  or  the  hot  wire  the  division  should 
be  made  deliberately,  and  care  taken  not  to  drag  upon  the  parts. 

In  regard  to  anesthesia :  In  simple  amputation  of  one,  or  even 
both,  palatal  tonsils  in  a  fairly  tractable  child,  no  anesthetic  is  nec- 
essary. Even  with  an  intractable  patient,  if  efficient  assistants  are 
at  hand,  anesthesia  may  be  dispensed  with.  Tonsillotomy,  while 
disagreeable  to  the  patient,  is  not  painful.  As  to  pain,  there  is  no 
comparison  between  tonsillotomy  and  the  extraction  of  a  tooth.  Ton- 
sillotomy is  less  painful  than  the  adenoid  operation  when  done  with  a 
curette.  But  if  adenoids  and  palatal  tonsils  are  both  to  be  removed 
it  is  better  to  give  an  anesthetic.  In  any  case  the  anesthetic  makes 
the  operation  much  more  comfortable  for  all 
concerned,  and  in  case  the  snare  is  to  be  used 
it  is  imperative.  Any  general  anesthetic  may 
be  used.  Nitrous  oxide  alone  scarcely  gives 
time  enough.  Cocaine  may  be  used  in  older 
children.  But  as  the  general  anesthetic  is  used 
more  on  account  of  fright  than  pain,  cocaine 
does  not  take  its  place;  and,  besides,  children 
are  not  all  equally  susceptible  to  cocaine.  It 
is  not  wise  to  undertake  the  operation  upon 
any  child  without  assistance  at  hand  adequate 
to  control  the  patient  in  any  event,  and  a 
„       ^o  mouth  gag  should  always  be  used.     A  conven- 

Mason'sVouth  Gag.  ient  form  is  shown  in  Fig.  168.  A  child  per- 
fectly docile  at  first  may  become  frightened 
into  a  panic  and  make  a  desperate  resistance  after  only  one  tonsil 
has  been  removed,  or  perhaps  while  alarming  hemorrhage  is  taking 
place. 

In  holding  a  patient's  head  and  gag,  the  assistant  should  draw 
the  gag  backward  between  the  jaws  and  keep  away  from  the  trigger 
which  allows  the  gag  to  collapse. 

If  a  general  anesthetic  is  used  the  position  is  dorsal,  with  the 
head  drawn  over  the  end  of  the  table,  as  described  under  operation 
for  adenoids.  If  no  anesthetic  or  a  local  anesthetic  is  used,  the 
position  is  the  same  as  the  sitting  position  for  intubation.  If  both 
tonsils  and  adenoids  are  to  be  removed  the  tonsils  should  come  first. 
As  to  hemorrhage :  It  is  well  to  pause  after  removing  each 
tonsil  long  enough  to  see  whether  the  hemorrhage  is  excessive.  I 
have  never  met  serious  hemorrhage  after  excision  of  the  tonsils, 
though  at  times  it  has  been  so  sharp  as  to  cause  uneasiness  lest  it 
continue ;  and,  having  questioned  surgeons  and  laryngologists  of 
my  acquaintance,  who  also  have  performed  very  numerous  tonsil- 
lotomies, I  find  that  none  of  them  have  ever  had  a  death,  and  very 
seldom  experienced  any  really  dangerous  hemorrhage.     Owen  says 


466  SURGICAL   DISEASES    OF    CHILDREN 

serious  bleeding  is  exceptional.  Ashby  and  Wright :  "  We  have 
never  seen  bleeding  follow  the  operation  to  any  serious  extent." 
Yet  cases  are  on  record  where  the  danger  was  escaped  only  by 
using  active  means  for  hemostasis ;  and  numerous  cases  have  oc- 
curred of  blood  loss  which  greatly  retarded  the  patient's  recupera- 
tion. Bearing  these  facts  in  mind,  on  the  general  principle  that  it 
is  well  to  be  saving  of  blood  while  operating,  it  is  a  good  plan  to 
have  always  at  hand  the  means  for  controlling  hemorrhage.  I  have 
been  in  the  habit  of  making  ready  a  swab  or  stick-sponge,  dipped  in 
a  saturated  solution  of  tannin  and  alum  in  glycerine,  and,  after  the 
first  rush  of  blood  from  the  severed  tonsil  had  been  cleared  away, 
applying  the  stypic,  with  pressure,  to  the  bleeding  surface.     In  case 


Fig.  169.     Stoerck's  Toxsil  Hemostat. 

of  more  persistent  bleeding  from  an  open  vessel,  one  or  two  hemo- 
static forceps  or  a  tenaculum  or  vulsellum  will  enable  one  to  deal 
with  it.  R.  J.  Levis  suggested  a  plan  of  thrusting  a  tenaculum 
deeply  through  the  tonsil,  under  the  bleeding  vessel,  or  through  the 
base  of  the  whole  tonsil  if  bleeding  is  general,  and  by  giving  the 
instrument  a  decided  twist,  sufficient  torsion  is  used  to  control  the 
flow.  By  closing  the  teeth  tightly  on  the  projecting  handle  of  the 
tenaculum  and  bandaging  the  jaws  tightly  together  the  torsion  is 
maintained.  Or  a  gauze  sponge,  squeezed  out  of  water  as  hot  as 
can  be  borne,  may  be  applied.  Or  hot  water  projected  against  the 
bleeding  surface  from  a  syringe.  Various  special  instruments  have 
been  devised  as  tonsil  hemostats.  For  instance,  Stoerck's.  (Fig, 
169.)  As  may  be  surmised  from  the  cut,  one  blade  is  intended  to  be 
passed  within  the  mouth,  the  oval  pad  placed  upon  the  bleeding  sur- 
face, while  the  other  is  placed  externahy.  The  blades  are  then 
clamped  together  by  the  bolt  and  fly-nut,  and.  the  handles  being  re- 
movable, the  instrument  can  be  shortened  and  left  in  position  as  long 
as  may  be  desirable.  Dr.  Beverley  Robinson  describes  "  as  a  more 
useful  instrument,"  "  A  long  metallic  holder,  with  a  convex  metal 
button,  somewhat  larger  than  a  penn}',  projecting  from  its  distal 


SURGERY    OF   AIR    PASSAGES  467 

extremity,  supported  by  a  firm  metal  rod  half  an  inch  in  length. 
Around  this  button  a  thick  layer  of  sheet  spunk  may  be  wrapped 
or  tied  tightly.  .  .  .  This  instrument  is  far  preferable  to  differ- 
ent kinds  of  double-clamp  pressure  forceps  which  have  been  de- 
scribed." 

Less  rapid,  but  persistent,  hemorrhage  may  be  held  in  check 
by  the  use  of  the  tanno-gallic  mixture,  sometimes  called  Mackenzie's 
mixture,  com.posed  of  tannic  acid,  six  drachms ;  gallic  acid,  two 
drachms ;  water,  one  ounce.  Of  this  a  half  teaspoonful  should  be 
sipped  and  swallowed  at  short  intervals. 

When  adrenalin  chloride  and  similar  preparations  of  the  supra- 
renals,  by  whatever  name  known,  were  introduced  to  the  profession 
it  was  expected  that  one  of  its  fields  of  usefulness  would  be  in  ton- 
sillotomy, and  it  was  extensively  tried.  But  it  was  found  to  tempo- 
rarily shrink  the  tissues  to  such  a  degree  as  to  materially  interfere 
with  the  operation ;  and  that,  although  hemorrhage  was  lessened  for 
the  time  being,  it  was  liable  to  occur  when  the  effect  of  the  drug 
had  passed. 

The  after  treatment  of  tonsillotomy  cases  is  simple,  consisting 
in  the  use  of  protection  against  taking  cold  for  several  days ;  soft, 
unirritating  foods,  and  of  bland  gargles  or  sprays  of  normal  salt 
or  potassium  chlorate,  or  argyrol  solution,  sometimes  followed  by 
a  protective  coating  of  liquid  vaseline,  and  the  avoidance  of  dust. 
Spongy  granulations  may  need  the  application  of  a  solution  of  sil- 
ver nitrate  or  tannic  acid,  alum,  hamamelis  or  similar  astringent. 
Iodine  or  strong  solution  of  argyrol  may  be  useful.  After  operation 
a  persistent  use  of  general  tonics,  hematinics,  and  often  anti-rheu- 
matics, aids  improvement. 

THE    UVULA 

The  uvula  may  be  chronically  enlarged  as  a  result  of  repeated 
inflammation,  leading  to  hypertrophy ;  or  its  mucous  membrane  may 
be  so  redundant,  or  its  muscular  fibers  so  relaxed  as  to  produce  per- 
sistent cough  or  snoring  and  thick  speech.  Snipping  ofif  a  portion 
is  the  remedy. 

I  once  knew  a  case — a  babe  of  twenty  months — which  came  to 
me  as  an  instance  of  "  double  tongue."  What  appeared  like  a  small 
tongue,  nearly  one-third  of  the  width  and  one-third  of  the  length  of 
the  normal  tongue,  rested  upon  the  latter  organ,  with  its  free  .end 
forward.  It  occasioned  a  very  considerable  obstruction  to  breathing 
and  swallowing,  especially  when  it  was  pushed  backward  into  the 
pharynx,  as  sometimes  occurred.  The  growth,  upon  examination, 
proved  to  be  the  uvula,  or  to  have  its  attachment  to  the  uvula,  and 


468  SURGICAL   DISEASES    OF    CHILDREN 

was  probably  a  papilloma.  The  parents  refused  operation,  as  they 
had  found  begging  profitable  by  exhibiting  "  the  baby  with  two 
tongues." 

OBSTRUCTION    BY    THE    SOFT    PALATE 

The  free  opening  between  the  post-nasal  space  and  the  pharynx 
may  be  interfered  with  by  congenital  deformity  of  the  velum  palati, 
or  by  its  adhesion  to  the  post-pharyngeal  wall  and  cicatricial  con- 
traction as  a  result  of  diphtheritic  or  other  inflammation.  Such  cases 
may  be  improved  by  plastic  operation  and  the  use  of  dilators  adapted 
to  the  peculiarities  of  each  case,  with  the  object  of  increasing  and 
maintaining  the  patency  of  the  naso-pharyngeal  space. 

FOREIGN    BODIES    IN    THE    NOSE 

Inanimate  Bodies. — No  class  of  patients,  not  even  the  de- 
mented or  insane,  present  so  many  cases  of  foreign  body  in  the  nose 
as  do  children.  The  practice  of  placing  them  there  is  by  no  means 
conjfined  to  the  feeble-minded,  though  for  the  most  part  to  quite 
young  children.  Some  children  have  a  propensity  to  repeat  the  per- 
formance. Almost  any  article  of  a  size  and  shape  to  be  easily  ad- 
mitted to  the  nostrils  may  be  introduced.  Beans,  buttons,  paper 
wads,  pebbles,  bits  of  pencil  are  examples  of  the  commonest. 

The  patients  do  not  by  any  means  always  come  to  the  surgeon 
with  a  history  of  a  foreign  body.  In  many  cases  such  a  condition 
is  not  even  suspected  by  parents  or  nurse. 

The  foreign  body  may  be  lodged  in  any  of  the  nasal  fossae, 
most  frequently  the  inferior  meatus,  but  may  have  been  thrust  higher 
or  farther  back.  In  a  recent  case  the  delicate  vascular  and  sensi- 
tive lining  of  the  nasal  canals  might  be  scarcely  more  than  irri- 
tated, or  might  be  acutely  inflamed  and  greatly  swollen,  depending 
on  the  size,  shape,  and  consistency  of  the  offending  body  and  length 
of  time  it  had  been  present.  In  older  cases  often  ulceration  has 
taken  place,  with  muco-purulent  discharge  or  the  formation  of  abun- 
dant soft  granulations  which  bleed  at  a  touch  or  upon  blowing  the 
nose.  The  swelling  and  inflammation  may  even  be  perceptible 
externally  upon  the  nose.  As  a  rule,  hard,  impervious  bodies,  like 
buttons  or  pebbles,  make  less  disturbance  than  one  which  becomes 
saturated  with  discharges  and  fetid.  A  foreign  body  remaining" 
long  in  the  nose  may  become  incrusted  with  the  salts  of  the  dis- 
charges, phosphate  or  carbonate  of  lime-^^ — a  so-called  rhinolith. 
Numerous  instances  are  on  record  of  foreign  bodies  remaining  in 
the  nose  for  many  months,  and  even  for  many  years,  before  they  w.ere 
discovered,  and  this  notwithstanding  that  a  number  of  doctors  had 
been  visited,  who  had  given  treatment  for  catarrh  or  other  ailment. 

One  of  my  cases  came  with  a  history  of  obstructed  breathing, 


SURGERY    OF    AIR   PASSAGES  469 

purulent,  fetid,  and  sometimes  bloody  discharge  of  several  weeks' 
duration.  The  patient  was  a  child  of  some  four  years.  The  nose 
was  swollen  externally  and  tender.  On  introducing  a  probe  it 
encountered  an  elastic  mass  and  was  followed  by  a  flow  of  blood. 
For  a  moment  I  paused  to  consider  the  possibilities  of  abscess  with 
necrosis,  of  sarcoma,  angioma,  or  lupus.  But,  exploring  with  the 
forceps,  I  felt  something  fibrous,  and,  taking  a  strong  hold,  drew 
forth  a  sponge  of  the  size  of  a  hickory-nut. 

Every  case  presenting  obstruction  to  the  breathing  or  discharge 
from  the  nose  should  be  very  carefully  examined.  If  the  obstruction 
or  discharge  be  upon  one  side  only  one  is  especially  suspicious  of 
a  foreign  body,  and  more  so,  as  Holmes  remarks,  if  the  mucous  lin- 
ing of  the  other  side  is  absolutely  healthy.  However,  search  should 
be  made  for  deviated  septum,  which  is  rather  common;  or  an  en- 
larged turbinate,  which  is  more  unusual;  or  polypus,  which  is 
uncommon ;  or  the  rare  angioma  or  other  growths.  Syphilitic  ozena 
is  bilateral.  In  some  cases  the  foreign  body  will  be  detected  at  a 
glance  or  at  the  first  passing  of  the  probe.  In  nearly  every  case 
anterior  rhinoscopy,  after  careful  removal  of  the  discharges  with 
warm  normal  salt  or  sodium  bicarbonate  solution,  or  the  use  of  the 
probe,  will  make  the  diagnosis. 

If  the  parts  are  too  sensitive  to  allow  satisfactory  examination, 
cocaine  may  be  used.  Adrenalin  chloride  helps  by  still  further 
shrinking  the  tissues.  An  effort  may  be  made  to  expel  the  body  by 
closing  the  open  nostril  and  directing  the  patient  to  blow  forcibly 
through  the  obstructed  one.  Or  by  driving  a  stream  of  warm  salt 
solution  into  the  open  nostril,  the  mouth  being  held  open.  Or,  if 
necessary,  a  general  anesthetic  may  be  administered. 

A  dressing  forceps  may  seize  the  body  very  well  if  it  be  of 
yielding  material.  But  usually  a  loop  of  wire  or  a  scoop  is  better 
for  a  round,  hard  body,  being  more  easily  slipped  by  so  as  to  draw 
from  behind.  A  very  good  combination  of  loop  and  scoop  is  made 
by  bending  the  closed  end  of  a  hairpin.  Or  a  Bellocq's  canula,  or  the 
finger  passed  through  the  posterior  nares  may  thrust  the  foreign 
body  out  forward.  There  is  some  risk  in  pushing  it  back  into  the 
pharynx,  lest  it  fall  into  the  larynx.  A  rhinolith  embedded  in  the 
tissues  may  have  to  be  crushed  before  it  can  be  removed.  In  some 
cases  the  habit  of  thrusting  foreign  bodies  into  the  nose  may  be 
cured  by  removing  one  without  an  anesthetic.  In  all  ordinary  cases, 
after  the  offending  substance  has  been  removed,  it  is  surprising 
how  rapidly  repair  takes  place,  although  considerable  ulceration  and 
distension  has  occurred.  A  simple  antiseptic  wash  "of  boric  acid  or 
weak  carbolic  acid,  or  even  normal  salt  solution,  carefully  warmed 
to  blood  heat,  is  all  that  is  required ;  but  a  powder  or  a  salve,  such 
as  campho-phenique  or  vaseline,  may  afterward  be  applied. 


470  SURGICAL   DISEASES    OF    CHILDREN 

Flies  or  Their  Larv^  in  the  Nasal  Passages. — Cases  of 
flies  or  their  larvae  in  the  nose  or  its  accessory  sinuses  I  have  never 
met,  and  must  borrow  an  account  from  other  writers.  A  good 
summary  is  given  by  Dr.  Delavan  in  "  Keating's  Cyclopedia."  Most 
of  the  cases  have  occurred  in  tropical  or  warm  countries.  A  fly 
of  the  order  muscidse  enters  the  nostril  of  a  sleeping  person  and  there 
deposits  its  eggs.  These  are  quickly  hatched  and  cause  tickling 
and  sneezing,  and  then  irritation,  formication,  bleeding  with  red- 
ness of  face,  eyelids,  and  excruciating  pain,  often  erysipelas,  frontal 
headache,  and,  unless  properly  treated,  convulsions,  coma,  and 
death.  The  local  symptoms  and  appearances  might  vary  somewhat, 
according  to  the  principal  location  of  the  larvse — for  instance,  in  the 
frontal  sinus  or  in  the  antrum  of  Highmore.  Rapid  and  extensive 
destruction  of  mucous  membrane,  cartilages  and  bones  have  been 
occasioned  in  this  horrible  manner  in  cases  not  soon  recognized  or 
not  energetically  and  properly  treated. 

The  diagnosis  is  easy  if  one  can  get  a  sight  of  a  larva,  either 
upon  examination  or  by  its  being  sneezed  out.  Formerly  such  cases 
were  treated  by  syringing  with  solutions  of  tannin,  alum,  tobacco 
and  the  like,  or  insufllations  of  snuff  or  calomel.  Dr.  Delavan's 
article  refers  to  the  more  commendable  method  of  Dr.  John  Ellis 
Blake.^  This  consists  in  the  use  of  vapor  of  chloroform  or  ether, 
preferably  chloroform,  applied  to  the  nose  or  to  the  infested  sinus. 
The  larvse,  to  escape  suffocation  from  the  vapor,  escape  to  the  open 
air.  This  plan  has  the  great  advantage  of  not  merely  destroying 
the  pests,  but  of  removing  them.  The  use  of  cocaine  or  cocaine  and 
adrenalin  previously  to  the  anesthetic  by  opening  the  sinus  as  wide 
as  possible  for  the  ingress  of  the  vapor  and  the  egress  of  the  mag- 
gots, as  well  as  relieving  the  pain,  would  work  to  great  advantage. 
Cases  of  other  living  things — for  example,  ascarides,  ticks,  leeches, 
and  so  forth — have  occasionally  been  reported.  Sternutatories  are 
recommended.    Removal  with  forceps  may  be  necessary. 

FOREIGN    BODY    IN    THE    GULLET 

Foreign  body  in  the  gullet  may  cause  obstruction  to  the  air 
passage,  and  is  therefore  mentioned  in  this  place.  It  will  be  dis- 
cussed in  connection  with  the  esophagus. 

TONGUE  SWALLOWING 

This  is  a  not  very  infrequent  condition,  in  which  the  length  and 
mobility  of  the  tongue  are  sufficient  to  allow  it  to  be  turned  back- 
ward into  the  gullet,  thus  obstructing  the  breathing,  even  threaten- 
ing suffocation.    Usually  watching  the  babe  and  drawing  the  tongue 

1  Boston  Med.  and  Surg.  Jour.,  April  lO,  1862. 


SURGERY   OF  AIR    PASSAGES  471 

forward  with  the  finger  is  sufficient  to  reHeve  it ;  and  later,  better 
control  of  the  organ  ensues.  Mr.  Owen  suggests  the  propriety  of 
plastic  operation  in  the  floor  of  the  mouth  to  secure  sublingual  ad- 
hesions ;  and  that  even  tracheotomy  might  be  demanded  as  a  pre- 
caution against  fatal  dyspnea. 

RETRO-PHARYNGEAL,   OR   POST-PHARYNGEAL   ABSCESS 

Retro-pharyngeal  abscess  is  a  disease  not  at  all  infrequent  in 
both  infants  and  children,  and  one  which  is  singularly  insidious  and 
apt  to  be  mistaken  for  some  other  disease. 

Practically  the  condition  may  be  divided  into  two  varieties — 
acute  and  chronic. 

As  to  etiology,  the  acute  form  usually  depends  upon  the  pres- 
ence of  pyogenic  organisms  often  found  in  throat  or  larynx,  or  adja- 
cent tissues  of  mouth,  middle  ear,  or  nares.  It  is  apt  to  follow, 
although  sometimes  rather  remotely,  a  more  superficial  inflamma- 
tion, such  as  tonsilitis,  pharyngitis,  scarlatinal  angina,  diphtheria, 
measles,  otitis  media,  purulent  rhinitis,  although  in  some  cases  no 
history  of  previous  inflammation  can  be  elicited  and  no  probable 
cause  found.  It  may  be  due  to  direct  injury  or  to  burrowing  of  an 
abscess  originating  elsewhere. 

The  chronic  form  is  an  accompaniment  of  caries  of  the  cervical 
spine,  the  active  organism  most  frequently  responsible  being  the 
tubercle  bacillus.  The  acute  abscess  is  usually  situated  in  a  lym- 
phatic gland  located  about  the  level  of  the  axis,  or  in  the  loose  areolar 
tissue  between  the  pharynx  and  the  fascia  of  the  pre-vertebral 
muscles,  especially  if  it  has  tracked  from  the  ear  or  tonsillar  region. 

In  the  chronic  form  resulting  from  spondylitis,  or  Pott's  disease 
of  the  cervical  spine,  the  pus,  or  that  which  resembles  pus,  collects 
behind  the  deep  fascia  and  the  anterior  common  ligament.  It  is 
well  to  note  in  this  connection  that  retro-esophageal  abscess  may 
occur,  its  location  being  sufficiently  indicated  by  its  name. 

Symptoms. — The  symptoms  in  the  acute  variety  of  retro- 
pharyngeal abscess  are  fever  and  malaise,  fret  fulness  and  anorexia, 
dysphagia,  stiffness  of  the  neck  muscles,  dyspnea,  altered  voice, 
which  may  be  somewhat  nasal  or  more  hollow,  so-called  "  duck 
voice."     (Duparque  and  Labric.) 

The  alteration  in  voice  and  the  dyspnea  varies  with  the  amount 
and  situation  of  the  swelling",  and  is  usually  sufficient  to  attract 
attention  to  the  throat.  However,  if  the  abscess  is  small  or  situated 
low  down  or  is  somewhat  flat,  even  the  routine  inspection  of  the 
throat  may  fail  to  discover  it.  Or  if  the  tonsils  or  pharynx  are 
inflamed,  or  there  is  chronic  enlargement  of  the  tonsils,  or  adenoids 
are  present,  or  hoarseness,  or  croupy  cough,  attention  is  apt  to  be 
diverted  from  the  real  trouble.     The  fever  and  other  evidences  of 


472  SURGICAL  DISEASES    OF   CHILDREN 

acute  onset  of  illness  may  be  so  slight  that  the  fretfulness  and  evident 
discomfort  and  the  failure  to  drink  or  eat  are  attributed  to  widely 
different  causes.  Usually  the  dyspnea  when  produced  by  retro- 
pharyngeal abscess  is  continuous,  but  I  have  seen  it  come  paroxys- 
mally,  resembling  laryngismus. 

History  or  complications  may  be  misleading.  Once  being 
called  to  a  child  in  the  fifth  week  after  severe  diphtheria,  and  hearing 
its  nasal  voice  and  witnessing  its  dysphagia,  the  food  also  regurgitat- 
ing through  the  nose,  my  first  idea  was  of  post-diphtheritic  paralysis. 
And  this  was  correct.  But  on  examining  further  I  found  also  a 
retro-pharyngeal  abscess  which  the  symptoms  of  paralysis  had  very 
nearly  led  me  to  overlook. 

Diagnosis. — The  diagnosis  is  easily  made  in  most  cases  if  only 
one  bears  in  mind  the  possibility  of  this  disease.  The  tumor  may 
point  in  the  middle  line,  or  more  laterally  so  as  to  blend  with  a  tonsil- 
lar enlargement.  It  may  be  so  high  or  so  low  as  not  to  come  into 
view  on  inspection  and  only  be  discovered  by  touching  with  the 
finger,  which  should  always  be  employed  in  such  an  examination. 
The  abscess  wall  may  be  so  thin  and  distended  that  pus  will  show 
through,  and  feel  soft  and  fluctuating;  or  it  may  be  so  deep  and, 
early  in  the  case,  the  tumefaction  may  be  so  flat,  as  to  be  difficult 
of  detection  by  palpation.  In  examining  with  the  finger  the  child 
must  b,e  held  and  the  mouth  kept  open  as  described  in  examining  for 
adenoids.  Even  the  infant  with  no  teeth  can  pinch  severely.  The 
examination  should  be  made  deliberately,  in  perfect  safety,  with  the 
bare  finger.  The  metal  finger-shield,  such  as  used  by  some  in  intu- 
bation, is  a  hindrance.  Movements  of  the  head  are  more  painful,, 
leading  to  more  resistance  and  fixation  of  muscles  than  one  finds 
in  tonsilitis,  in  croup,  or  in  passive  edema  of  the  glottis.  Pressure 
over  the  sides  and  particularly  the  front  of  the  throat  increases  pain 
and  dyspnea.  Only  a  careless  examiner  would  mistake  the  condi- 
tion for  croup  or  bronchitis.  Angioma  or  edema  of  the  glottis  would 
require  more  care  to  differentiate.  Many  a  case  of  retro-pharyngeal 
abscess  has  for  some  days  been  mistaken  for  tonsilitis. 

Prognosis. — In  the  acute  form  the  disease  runs  its  course  in 
from  ten  days  to  five  or  six  weeks.  It  may  rupture  spontaneously 
or  burrow  farther  down  into  neck  or  thorax.  There  is  danger  of 
suffocation  if  the  swelling  be  large  enough  to  compress  the  larynx 
or  trachea  or  if  it  produce  edema  glottidis.  If  it  discharge  its  con- 
tents into  the  air  passages  it  may  produce  sudden  death,  or  set  up 
a  pneumonia.  Fatal  hemorrhage  may  ensue  upon  erosion  of  a 
blood-vessel. 

The  majority  of  cases  get  well  if  discovered  and  properly 
treated. 

Treatment. — If  a  retro-pharyngeal  phlegmon  is  discovered  be- 


SURGERY    OF   AIR    PASSAGES  473 

fore  pus  formation  can  be  detected,  the  early  treatment  may  be  con- 
fined to  general  antiphlogistic  remedies  and  supporting  the  patient ; 
but  as  soon  as  abscess  can  be  detected  it  should  be  opened.  In  the 
ordinary  acute  form  with  the  pus  collection  anterior  to  the  fascia 
of  the  prevertebral  muscles  and  pointing  in  the  pharynx,  the  opening 
is  best  made  in  that  situation.  I  can  see  no  advantage  in  dissecting 
deeply  through  sound  tissues  at  the  side  of  the  neck  to  discharge 
an  abscess  located  superficially  and  anatomically  accessible  through 
the  pharynx.  The  chronic  abscess  due  to  spondylitis,  or  other  origin, 
or  the  acute  abscess  but  deeply  seated,  is  a  different  problem,  and 
will  be  considered  later.  As  to  the  method  of  opening  the  abscess: 
I  do  not,  as  some  French  surgeons  have  advised,  use  an  aspirator 
or  trocar  before  incision,  with  the  idea  of  preventing  suffocation  by 
the  sudden  rush  of  the  pus  into  the  throat.  There  is  a  positive  dis- 
advantage in  the  preliminary  aspiration,  by  making  the  bulging  less 
distinctly  felt  or  seen  and  also  of  increasing  the  liability  of  cutting 
deeper  than  the  anterior  wall  of  the  abscess.  Nor  can  I  agree  with 
the  directions  given  by  Mr.  Owen,  who  says,  "  The  patient  should 
be  anesthetized ;  when  he  is  propped  in  the  sitting  posture,  the  head 
should  be  brought  well  forward,  and,  the  mouth  being  fixed  open 
by  a  gag,  a  free  incision  made  into  the  bulging  tumor  with  a  guarded 
bistoury." 

Nor  with  Dr.  Grenet,  who  says :  "  The  child  then  is  seated  in  the 
assistant's  lap  with  the  head  held  straight  and  fixed,  and  the  mouth 
well  opened  by  a  gag;  no  anesthetic  is  required.  .  .  .  The 
child's  head  must  be  sharply  bent  forward  so  that  the  pus  may  be 
expelled  outside  .  .  ."  The  object  of  putting  the  patient  in  this 
position  is  to  avoid  the  pus  being  "  drawn  with  a  convulsive  inspira- 
tion into  the  larynx,  and  the  child  suffocated  "  (Owen),  or  "  of  its 
falling  into  the  windpipe,  giving  rise  to  spasm  of  the  glottis  " 
(Grenet). 

For  the  ready  exit  of  the  pus,  the  safety  of  the  patient  under 
anesthesia,  as  well  as  the  convenience  of  anesthetizer  and  operator, 
a  preferable  position  of  the  patient  is  lying  horizontally  or  with  the 
head  lowered  and  turned  to  one  side,  usually  the  side  upon  which 
the  abscess  is  located  if  it  be  lateral  An  anesthetic  may  be  used; 
but  in  the  majority  of  cases  may  well  be  dispensed  with.  The  gag 
is  a  necessity.  The  incision  may  be  readily  made  with  a  guarded 
bistoury,  at  the  most  fluctuating  point  felt  by  the  left  index  finger. 
In  most  cases  I  prefer  to  use  as  more  convenient  a  sharp-pointed 
scissors,  thrusting  in  the  points  with  the  instrument  closed  and  then 
spreading  the  blades  to  make  a  free  opening ;  besides,  such  a  wound 
bleeds  less  and  is  not  so  apt  to  adhere  at  its  edges  and  close  before 
drainage  is  complete.  One  makes  the  opening  vertically  and  as  near 
the  median  line  as  the  situation  of  the  abscess  cavity  will  allow.     The 


474  SURGICAL   DISEASES   OF   CHILDREN 

abscess  should  be  emptied  by  pressure  of  the  finger  or  stick  swabs 
and  the  throat  and  mouth  washed  out  with  boracic  acid  or  other 
mild  solution.  The  cavity  may  refill  and  require  reopening,  but  not 
usually  if  the  first  opening  be  as  free  as  it  should  be. 

CHRONIC    RETRO-PHARYNGEAL    ABSCESS 

The  chronic  form  of  retro-pharyngeal  abscess  usually  arises  in 
cervical  caries  and  presents  the  longer  history  of  stiffness  of  the 
neck  muscles,  the  restricted  head  movements,  the  characteristic  at- 
titude and  the  pain  and  tenderness  which  belong  to  that  disease.  It 
will  not  present  the  febrile  disturbance  of  the  acute  variety,  though 
there  may  be  hectic.  The  most  frequent  seat  of  cervical  spondylitis 
is  in  the  bodies  of  the  third,  fourth,  and  fifth  vertebrae.  In  a  less 
number  of  cases  the  two  upper  vertebrae  are  diseased,  although 
rarely  these  two  alone.  Whatever  the  exact  location  of  the  lesion, 
the  weight  of  the  head,  or  an  extra  weight  upon  the  head,  or  jarring 
is  badly  borne;  and  the  attitude  is  such  as  best  to  avoid  jarring  of 
the  diseased  area,  usually  the  cervical  spine  being  curved  backward 
while  the  spine  below  is  curved  forward.  Often  torticollis  is  pres- 
ent, usually,  though  not  invariably,  when  the  disease  is  in  the  lower 
cervical  region.  In  the  torticollis  of  cervical  spondylitis  the  head  is 
rotated  toward  the  contracted  muscle,  while  in  congenital  wry-neck 
the  head  is  turned  in  the  opposite  direction.  The  symptoms  of  pain, 
and  reflex  muscular  spasm  with  limitation  of  motion  will  vary  some- 
what with  the  location  of  the  lesion.  Pain  is  referred  to  the  periph- 
ery of  the  nerves  irritated,  therefore,  those  arising  at  or  below 
the  diseased  point.  In  atlo-axoid  disease  the  pain  is  in  the  upper 
part  of  the  neck  about  the  ear  or  occiput,  though  it  may  extend  to 
the  upper  part  of  the  thorax.  In  disease  of  the  lower  cervical 
vertebrae  the  pain  is  felt  lower  on  the  sides  of  the  neck,  extending 
into  the  arms  and  chest.  In  atlo-axoid  disease  reflex  muscular  spasm 
is  most  marked  in  the  rotators  of  the  head,  whereas  with  the  dis- 
ease below  the  nervous  supply  of  the  rotators  the  flexors  and  exten- 
sors of  the  neck  are  thrown  into  contraction.  Attempts  at  rota- 
tion or  of  flexion  and  extension  will  discover  in  which  direction 
motion  is  limited,  and  the  probable  location  of  the  disease.  If 
the  disease  have  advanced  so  far  as  to  destroy  nervous  tissue  or 
seriously  compress  it,  paralysis,  motor  or  sensory,  generally  motor, 
and  corresponding  in  location,  will  result.  Meningitis  may  occur. 
Sudden  collapse  of  diseased  bone  may  crush  the  cord  fatally. 

Spinal  caries  before  the  formation  of  abscesses  may  be  difficult 
to  distinguish  from  acute  trauma,  from  muscular  rheumatism,  from 
hysteria,  from  lateral  curvature  of  the  cervical  spine,  and  from 
adenitis ;  and  after  the  appearance  of  abscess  it  is  to  be  distinguished 
from  the  acute  variety,  from  mucous  cyst,  and  from  a  softened 
gumma,  or   an  angioma.     Traumatism  may   usually  be  excluded 


SURGERY   OF   AIR   PASSAGES 


475 


by  the  aid  of  the  history.     In  muscular  rheumatism  the  muscles 
themselves  are  sensitive  to  pressure,  the  condition  is  relieved  by  heat 
and  anti-rheumatic  medication,  and  a  little  time.     In  hysteria  the 
symptoms  are  subjective,  pain  being-  the  most  complained  of  and 
located  at  the  supposed  seat  of  the  disease  rather  than  in  peripheral 
nerveSa    Light  pressure  oc- 
casions    great     complaint, 
but     if    the     attention    be 
diverted  firm  pressure  can 
be  borne.     Reflex  spasm  is 
absent.     Any  apparent  de- 
formity   can   be    overcome 
if  the  patient's  attention  is 
drawn  to  some  other  exer- 
cise  or  he   be   directed  to 
lie  prone  on  the  table.     In 
lateral    curvature    there   is 
no    pain,    muscular    spasm 
or    limited    motion.     It    is 
uncommon    for   deeply   lo- 
cated adenoids  to  take  on 
inflammation      leading      to 
abscess     without     implica- 
tion of  those  more   super- 
ficially placed  where  their 
condition     could     be     de- 
tected.     It    should    not    be 
forgotten,  however,  in  the 
differential    diagnosis,    that 
more    than    one     diseased 
condition  may  be  co-exist- 
ent.    For    instance,    acute 
retro  -  pharyngeal     abscess 
or    acute   cervical    adenitis 
in    a    case    of    spondylitis. 
Fig.   170  shows  a  case  of 
cervical  spondylitis  in  which  also  extensive  adenitis  exists  and  has 
gone  to  suppuration.    Such  a  case  could  be  readily  mistaken  for  one 
of  adenitis  alone,  the  deeper  seated  bone  disease  being  overlooked. 
Acute  abscess  can  be  differentiated  by  its  history  and  febrile 
movement.     Mucous  cyst  has  no  pain,  tenderness,  fever,  or  muscu- 
lar reflexes,  nor  has  an  angioma,    A  gumma  could  probably  be  de- 
tected by  other  evidences  of  syphilis.     In  the  ordinary  case  of  cer- 
vical caries  which  has  advanced  as  far  as  disintegration  of  a  portion 
of  one  or  more  vertebral  bodies,  a  bulging  can  be  felt  on  examiination 
through  the  mouth,  and  we  have  the  chronic  retro-pharyngeal  ab- 
scess,  a  far  more  serious  kind  than  the  acute  form  before  described. 


Fig.  170.  Tuberculosis  of  lymphatic 
GLANDS  OF  THE  NECK  With  discharging 
sinus.  Caries  of  cervical  spine  also 
present.  No  connection  of  the  sinus 
with  the  spondylitis.  It  would  be 
very  easy  to  overlook  the  spondylitis 
in  such  a  case.     Boy  aged  3  years. 


476  SURGICAL   DISEASES    OF    CHILDREN 

Treatment. — The  treatment  of  cervical  spondylitis,  embracing 
as  it  does  hygienic  and  reconstructive  measures,  together  with  rest 
to  the  diseased  parts,  secured  either  by  position  or  fixative  apparatus 
or  both,  will  be  considered  in  the  Section  on  Tuberculosis  of  the 
Spine.  The  treatment  of  the  abscess  in  the  retro-pharynx  is  appro- 
priate here. 

In  marked  contrast  to  the  advice  to  open  the  acute  abscess  as 
soon  as  discovered,  one  counsels  delay  in  the  deep-seated — the  tuber- 
culous— the  chronic  form ;  unless  there  is  undoubted  fluctuation  or 
much  bulging  in  the  retro-pharynx  which  persistently  increase  after 
perfect  rest  to  the  parts  and  reconstructive  agencies  have  been 
faithfully  employed.  If,  however,  after  fair  trial  these  means  fail 
to  produce  a  subsidence  of  the  symptoms,  and  reabsorption  of  the 
swelling,  it  will  become  imperative  to  evacuate.  This  should  not 
be  done  through  the  retro-pharynx.  This  abscess  is  not  one  which 
will  run  an  acute  course  of  at  most  a  few  weeks  and  undergo  a 
reparative  process.  It  is  one  which  will  continue  for  months  or  years, 
in  connection  with  deep-seated  tuberculous  bone  disease,  and  is 
liable  to  become  secondarily  infected.  Therefore  the  opening  should 
be  external  where  the  cavity  can  be  drained,  disinfected  and 
dressed.  With  the  patient  under  anesthesia  and  the  skin  surgically 
cleansed,  an  incision  of  an  inch  length,  more  or  less,  should  be  made 
along  one  of  the  borders  of  the  sterno-mastoid  muscle  (anterior 
border,  according  to  Burkhardt,  posterior  border,  Chiene).  The  in- 
cision is  carried  only  through  the  skin  and  superficial  fascia,  avoiding 
any  visible  vein.  The  mouth  is  now  held  open  by  a  gag,  and  a 
grooved  director  thrust  into  the  incision  is  guided  by  the  index  finger 
of  the  other  hand,  toward  the  abscess  which  is  located  in  the  retro- 
pharynx.  When  the  abscess  is  reached  pus  will  flow  along  the  di- 
rector. A  hemostat  is  then  passed  along  the  groove  of  the  director 
into  the  cavity.  By  partly  opening  the  forceps  as  it  is  withdrawn  a 
sufficient  opening  is  made.  The  cavity  should  be  thoroughly  emptied 
and  irrigated  with  a  hot  antiseptic  solution,  a  drainage  tube  in- 
serted and  the  opening  covered  with  abundant  antiseptic  gauze  and 
pads  of  jute,  oakum  or  cotton  held  by  a  bandage. 

Complete  rest  to  the  parts  in  such  position  as  will  facilitate  free 
drainage,  secured  by  sandbags,  splints,  fixation  apparatus  with  all 
the  treatment  appropriate  to  spinal  caries  are  in  order.  At  first 
daily  dressing  and  irrigation  will  be  required,  iodine  and  iodoform 
being  the  antiseptic  agents  most  recommended.  Later  the  intervals 
between  dressing  may  be  longer,  if  there  is  no  temperature  and  the 
discharge  lessens  without  becoming  obstructed.  Finally  iodoform 
gauze  may  take  the  place  of  the  drainage  tube  and  it  in  time  be 
withdrawn  if  the  reparative  process  finally  warrants  the  closure  of 
the  sinus. 


CHAPTER  XVIII 

SURGERY    OF   THE    AIR    PASSAGES— Continued 

Edema  Glottidis — Acute  Simple  Laryngitis,  Spasmodic 
Laryngitis,  Syphilitic  and  Tubercular  Laryngitis — 
Tumors  of  the  Larynx — Foreign  Bodies  in  the  Larynx, 
Trachea  or  Bronchi — Membranous  Laryngitis  (Mem- 
branous Croup;  Diphtheritic  Croup;  True  Croup) — • 
Aeroporotomy. 

EDEMA   GLOTTIDIS 

This  swelling  of  the  mucous  and  submucous  tissues  of  the 
glottis  may  come  in  the  presence  of  the  general  anasarca  of  nephritis, 
or  accompany  the  local  manifestations  of  scarlet  fever,  measles, 
variola,  or  even  typhoid ;  may  be  induced  by  Ludwig's  angina — 
septic  cellulitis  in  proximity  to  the  larynx,  or  by  erysipelas,  or  ad- 
jacent peritonsilar  or  retro-pharyngeal  abscess.  Also  by  direct 
trauma,  scald  by  overheated  drinks,  or  steam  or  flame  and  smoke 
inhaled,  or  by  irritant  chemicals  or  foreign  bodies. 

The  condition  and  appearance  of  the  parts  will  vary  according  to 
the  cause  of  the  attack  and  the  period  at  which  it  is  examined. 
There  may  be  merely  an  accumulation  of  serous  fluid  in  the  cellu- 
lar tissues  with  very  little  change  of  color  which  is  lighter  if 
changed,  and  no  destruction  of  tissue ;  or  there  may  be  intense  in- 
flammation with  accompanying  deep  redness,  tense  swelling,  even 
ulceration  and  pus.  In  secondar}^  cases  lesions  of  a  primary  dis- 
ease may  be  very  evident ;  but  I  have  once  seen  dangerous  edema  of 
the  glottis  from  nephritis  following  an  unrecognized  scarlatina  in 
which  the  general  anasarca  was  so  slight  as  to  have  escaped  the 
notice  of  the  attending  physician  until  the  dyspnea  supervened.  The 
edema  of  the  glottis  is  always  a  serious  and  often  a  grave  condition. 
The  course  and  prognosis  depend  on  the  cause  and  severity.  Or- 
dinary scalds  or  burns  of  slighter  degree  will  be  recovered  from 
under  appropriate  treatment.  The  severe  ones  will  die  before  help 
reaches  them  or  from  resultant  bronchitis  and  pneumonia  in  spite 
of  treatment.^ 

^  See  Holmes'  Surgical  Diseases  of  Children,  p.  290,  et  seq. 

Ai77 


478  SURGICAL   DISEASES    OF   CHILDREN 

In  scalds  the  edema  does  not  usually  go  below  the  vocal  cords. 
There  may  be  some  resultant  scarring  and  contraction  at  the  rima 
glottidis.  Burns  from  inhaled  flame  and  smoke  are  more  grave,  as 
pneumonia  is  very  likely  to  occur.  In  all  accidental  cases,  shock, 
dysphagia  and  spasmodic  dyspnea  are  troublesome  additions  to  the 
constant  stenosis.  I  particularly  dread  cases  coming  with  septic 
celluitis — so-called  Ludwig's  angina,  a  streptococcic  infection  some- 
times secondary  to  scarlatina  or  diphtheria,  the  swollen  and  infected 
tissues  rendering  tracheotomy  difficult  and  dangerous.  Cases  with 
nephritis  can  be  tided  over  if  the  general  dropsy  subsides.  Too  often 
there  is  also  edema  of  the  lungs.  Cases  with  measles  recover  after 
intubation  unless  secondary  broncho-pneumonia  occurs  with  its  gluey 
and  tenacious  muco-pus.  All  cases  require  prompt  and  active  treat- 
ment or  suffocation  may  result. 

Treatment. — The  dyspnea  is  the  most  urgent  symptom,  and  at 
least  a  part  of  it  is  likely  to  be  spasmodic.  Mr.  Holmes  urges 
"  the  propriety  of  abstaining  from  operation  as  long  as  possible," 
and  employing  means  to  relieve  shock,  and  laryngeal  spasm,  and  to 
support  the  patient.  The  inhalation  of  warm,  moist  air  may  afford 
some  relief  to  the  spasm,  as  in  cases  of  ordinary  croup.  Also  the 
use  of  ipecacuanha ;  and  in  cases  resultant  from  accident  the  careful 
exhibition  of  an  opiate  to  quiet  pain  and  relieve  spasm  and  combat 
shock.  Stimulants  may  be  necessary.  In  the  more  passive  conges- 
tions the  use  of  cocaine  or  adrenalin,  alum  solution  3  to  5  grs.  to 
the  oz,  or  a  spray  of  picric  acid  locally  may  relieve  the  reflex  irrita- 
tion or  contract  the  swelling  for  a  time.  Inhalation  of  compound 
tincture  benzoin  from  hot  water  has  been  recommended.  In  the 
acute  nephritic  and  in  the  phlegmonous  cases  resulting  from  infec- 
tion the  heroic  use  of  mercury  is  indicated,  as  we  used  it  in  diph- 
theria and  "  membranous  crop,"  as  it  was  formerly  called,  before  the 
days  of  antitoxin.  A  grain  of  calomel  every  hour,  or  a  quarter  grain 
every  quarter  hour  may  be  given  until  purging  ensue ;  or  it  may  be 
used  by  inunction,  or,  better  still,  by  inhalation  of  sublimated  mer- 
cury under  a  tent,  as  originally  recommended  by  Corbin,  and  ad- 
vocated by  Northrup  and  many  others.  It  was  common  to  sublime 
5  grains  of  calomel  every  two  hours  for  two  days  and  nights,  and 
then  continue  at  intervals  of  three  hours  on  the  third  day  and  four 
hours  on  the  fourth  day.  Sometimes  in  urgent  cases  10  grains  were 
used  at  a  time  and  repeated  every  half  hour  for  four  or  five  times. 
Cases  were  reported  in  which  40  grains  were  used  every  hour  or 
two  hours  until  5000  grains  had  been  sublimated.  The  teeth  and 
mouth  should  be  well  washed  after  each  administration.  Leeches 
may  be  used.  In  streptococcic  cellular  infection  I  use  with  satis- 
faction a  combination  of  ichthyol,  mercury  and  iodine  (see  Section 
on  Septic  Cellulitis),  rubbing  it  in  gently  over  the  swelling  and  then 


SURGERY    OF    AIR    PASSAGES  479 

leaving  the  surface  smeared  with  the  ointment  and  covered  with 
oil  silk. 

Sthenic  cases  of  edema  are  relieved  by  ice  bags  over  the  larynx. 
Owen  quotes  with  approval  H.  D.  Palmer's  suggestion  of  using  in 
the  scald  or  burn  cases,  frequently  administered  doses  of  a  mixture 
of  cod-liver  oil  and  lime  water,  as  much  for  the  sake  of  a  dressing 
as  for  its  food  value.  It  is  probable  that  the  dysphagia  will  neces- 
sitate resort  to  rectal  feeding,  which  should  not  be  long  postponed 
but  carefully  and  systematically  employed.  If  the  dyspnea  becomes 
too  severe  operative  means  must  be  resorted  to.  Scarification  within 
the  larynx  is  more  talked  about  than  performed.  There  is  doubt 
about  its  doing  good  and  danger  of  doing  harm.  Notwithstanding 
that  much  has  been  said  against  intubation — of  its  injuring  the 
sv/ollen  and  softened  tissues — of  the  danger  of  making  false  passages, 
and  of  its  futility  in  ultimately  saving  the  life  of  the  patient — it 
will  probably  be  chosen,  at  least  as  a  tentative  measure,  by  surgeons 
familiar  with  it.  Tracheotomy  may  be  required  later.  If  there  be 
an  extreme  amount  of  dense  swelling  or  of  destruction  of  tissue, 
tracheotomy  will  be  the  choice  in  the  first  instance.  The  operation 
will  be  described  in  the  Chapter  on  Aeroporotomy. 

ACUTE    SIMPLE    LARYNGITIS,    SPASMODIC    LARYNGITIS, 
SYPHILITIC     AND     TUBERCULAR     LARYNGITIS 

It  is  seldom  that  mechanical  interference  is  necessary  in  acute 
simple  laryngitis  or  in  spasmodic  or  false  croup,  yet  the  surgeon 
is  occasionally  called  to  such  cases  and  should  remember  their  ex- 
istence. Their  differentiation  will  appear  in  the  diagnosis  of  diph- 
theria. 

Syphilis  of  the  larynx  is  frequent  in  infancy  as  one  of  the 
early  symptoms  of  the  hereditary  disease,  corresponding  to  the  sec- 
ondary manifestations  of  acquired  syphilis.  There  are  superficial 
lesions  and  hoarseness,  but  usually  no  stenosis.  The  more  severe 
evidences  of  the  tertiary  stage  are  seldom  found  affecting  ~  the 
larynx  in  early  life.  When  they  do  appear  it  is  in  older  children, 
attacking  the  epiglottis,  aryepiglottic  folds,  the  posterior  laryngeal 
walls,  and  vocal  cords,  presenting  deep  inflammation,  ulceration,  or 
condylomata.  Or  inflammation  of  the  cartilages  with  great  destruc- 
tion may  take  place,  producing  obstruction  to  the  passage  of  air 
during  the  inflammatory  process  or  by  contraction  during  healing. 

Treatment. — Intubation  is  resorted  to  with  great  relief  of  the 
dyspnea,  and  giving  much  better  results  than  tracheotomy.  The 
tube  may  have  to  be  used  for  weeks  or  months.  Potassium  iodide, 
iodide  and  mercury  should  be  used  early  and  energetically. 

Tubercular  Laryngitis  should  be  borne  in  mind  as  a  pos- 
sibility in  youth  or  adolescence.     I  have  never  seen  a  case  requir- 


48o  SURGICAL   DISEASES    OF   CHILDREN 

ing  surgical  interference  in  infancy  or  childhood.  Its  general  treat- 
ment is  that  of  tuberculosis,  which  is  also  usually  present  in  lungs, 
adjacent  glands  or  elsewhere.  Its  local  treatment  is  effective  only 
against  the  common  pyogenic  organisms  which  aid  the  tubercle 
bacillus  in  its  work  of  destruction.  Such  antiseptics  and  emollient 
agents  as  argyrol,  eucalyptol,  menthol,  guiacol,  creosote,  iodoform, 
in  aqueous  mixtures  or  with  albolene  or  liquid  vaseline  in  various 
proportions,  may  be  sprayed  or  injected  with  a  suitable  syringe  into 
the  larynx.  Nitrate  of  silver,  sulphate  of  zinc  or  other  powerful 
astringents  may  be  used  upon  the  lesions  by  skilled  hands. 

TUMORS  OF  THE  LARYNX 

The  tumors  of  the  larnyx  usually  enumerated  are  papilloma, 
granuloma,  fibroma,  myxoma,  chondroma,  sarcoma,  and  epithelioma. 
The  malignant  growths  might  almost  as  well  be  omitted,  as  they  al- 
most never  appear  in  children.  All  the  others  are  extremely  rare, 
excepting  the  first  two,  which  deserve  attention. 

Papilloma  is  the  commonest  tumor  of  the  larynx  in  childhood 
and  is  not  infrequently  met.  It  may  be  congenital  or  it  may  follow 
the  irritation  of  one  of  the  exanthems  in  older  children,  or  come 
from  no  discoverable  cause.  It  may  be  single  or  multiple,  peduncu- 
lated or  sessile;  and  situated  anywhere  between  the  epiglottis  to 
below  the  vocal  cords,  usually  upon  the  anterior  half  of  the  glottis, 
often  at  the  commissure,  but  may  be  attached  to  any  part.  The 
symptoms  are  hoarseness  of  long  standing,  chronic  cough,  some- 
times aphonia,  and  dyspnea  which  may  be  paroxysmal  or  con- 
tinuous. 

The  laryngoscope  should  always  be  employed  if  the  size  of  the 
fauces  permit,  even  if  local  or  general  anesthesia  is  necessary, 
and  may  discover  the  pink  or  whitish  warty-looking  growths.  Not- 
withstanding that  the  child  may  be  quite  docile,  and  trained  to  the 
examination,  or  cocaine  or  chloroform  used,  the  small  size  of  the 
parts  and  the  abundant  secretion  of  mucous  may  foil  the  examiner, 
and  compel  him  to  return  to  a  consideration  of  the  general  symptoms 
for  his  diagnosis.  Of  these  general  symptoms  spasmodic  fits  of 
dyspnea,  as  Holmes  remarks,  "  Seem  really  to  be  the  only  diag- 
nostic sign  between  tumor  of  the  larynx  and  chronic  laryngitis." 
Direct  inspection  by  Kilian's  method  may  succeed.  Tracheotomy 
for  exploratory  purposes  is  justifiable.     Prognosis  is  guarded. 

Treatment. — Intubation  might  afford  relief  and  cases  of  cure 
have  been  reported  by  its  use.  The  most  favorable  cases  for 
intubation  are  the  subcordal,  where  the  tube  can  exert  pressure  upon 
the  growth.  O'Dwyer's  foreign  body  tube  or  his  fenestrated  tube 
may  facilitate  endo-laryngeal  examination  or  endo-laryngeal  treat- 
ment. In  other  cases  the  presence  of  the  tube  seems  to  irritate  the 
neoplasm  and  hasten  its  growth.    A  single  papilloma,  and  especially 


SURGERY   OF   AIR    PASSAGES  481 

if  it  be  pedunculated,  can  be  removed  by  the  skillful  use  of  endo- 
laryngeal  methods — forceps,  or  snare  followed  by  chemical  or  elec- 
tro cautery.  But  multiple  and  particularly  sessile  growths  will 
probably  require  tracheotomy  or  thyrotomy.  (See  Chapter  on 
Aeroporotomy.)  On  account  of  the  liability  of  recurrence  of  the 
growths  when  removed  by  operation,  some  surgeons  have  preferred 
to  limit  the  operative  interference  to  a  tracheotomy,  the  growths 
disappearing  in  the  course  of  a  few  months  to  several  years,  when 
the  larynx  may  be  closed. 

Granulomata  of  the  Larynx  are  not  so  frequently  met  as 
formerly,  when  tracheotomy  was  more  often  practiced.  They  may 
occur  from  the  irritation  from  the  intubation  tube,  but  such  an 
occurrence  must  be  extremely  rare.  If  dyspnea  result  removal  would 
be  necessary.  Following  the  withdrawal  of  a  tracheotomy  tube  this 
can  sometimes  be  done  through  the  yet  unclosed  wound.  Thor- 
oughly removed  and  cauterized,  there  is  less  danger  of  recurrence 
than  with  papilloma.  The  same  may  be  said  of  polypus,  which  has 
been  reported  under  similar  conditions. 

FOREIGN  BODIES  IN  THE  LARYNX,  TRACHEA  OR  BRONCHI 

During  sudden  inspiration  while  laughing,  crying,  running, 
coughing,  sneezing  or  eating  or  from  fright,  a  foreign  body  is 
accidentally  drawn  or  falls  into  the  open  windpipe.  The  foreign 
body  may  be  any  small  article  a  child  may  have  to  play  with  or  to 
eat,  reported  cases  enumerating  such  objects  as  pins,  beads,  tacks, 
buttons,  corn,  peas,  beans,  fruit  stones,  nut  kernels  or  shells,  bits  of 
eggshell  or  bone  or  gristle,  a  morsel  of  meat  or  bread  crust,  a  lum- 
bricoid  worm  wandered  from  the  stomach,  or  a  caseating  gland  burst 
through  the  trachea,  or  an  intubation  tube  slipped  down  out  of 
reach  of  the  extractor.  Such  articles  as  ordinary  sized  coins,  mar- 
bles, whistles,  which  have  often  been  the  cause  of  choking,  have 
generally  done  so  by  sticking  in  the  gullet,  being  too  large  to  enter 
the  larynx. 

The  foreign  body  may  lodge  at  the  rima  glottidis,  in  the  ven- 
tricle of  the  larynx,  between  the  vocal  cords,  or  pass  on  into  the 
trachea,  or  into  a  bronchus,  more  often  the  right  on  account  of  its 
larger  size  and  more  direct  line  with  the  trachea.  In  any  of  these 
situations  it  may  be  loose  or  firmly  held,  and  may  cause  more  or 
less  local  damage  or  irritation  according  to  the  size  and  shape  and 
substance  of  the  foreign  body. 

The  symptoms  and  results  will  also  vary  with  the  size,  shape 
and  substance  of  the  offending  body,  and  its  point  of  lodgment. 
But  in  any  event  the  patient  is  suddenly  seized  with  violent  cough  and 
dyspnea,  which  are  spasmodic  and  apt  to  be  paroxysmal.  Dyspnea 
may  be  so  severe  as  to  produce  cyanosis,  congestion  of  the  vessels 
of  the  head  and  neck,  lachrymation,  distressing  restlessness  with 


482  SURGICAL  DISEASES    OF   CHILDREN 

clutching  at  the  air  or  at  the  mouth,  profuse  perspiration,  exhaus- 
tion, collapse,  convulsions  or  coma,  and  death.  Or  there  may  be 
periods  of  quiescence  lasting*  a  few  minutes  or  a  few  hours,  be- 
tween the  attacks  of  cough  or  dyspnea  or  of  rapid  respiration. 
There  is  suppressed  or  altered  voice  or  whistling  respiration.  Or 
the  symptoms  change  frequently,  with  a  shifting  of  the  position  of 
the  foreign  body.  Pain  in  the  region  of  the  windpipe  or  of  the 
chest,  or  bloody-mucous  expectoration  may  come  on,  or  tenderness 
to  external  pressure  over  the  front  of  the  neck.  Laryngitis,  trachei- 
tis, bronchitis,  or  pneumonia  may  develop. 

If  the  foreign  bod}^  become  impacted  in  a  bronchus,  collapse 
of  a  corresponding  portion  of  lung  will  likely  follow.  Atelectasis, 
abscess,  septicemia,  gangrene,  hemorrhage,  pleurisy,  pneumo-thorax 
are  all  possible  results.  The  foreign  body  may  be  spontaneously 
expelled  in  a  paroxysm  of  coughing  early  in  the  case,  or  with  much 
mucus,  pus  and  blood  even  after  abscess  has  formed,  and  recovery 
may  follow. 

Diagnosis. — Where  there  is  a  clear  history  of  a  child  having  in 
its  mouth  or  of  its  playing  with  some  article  which  has  since  dis- 
appeared synchronously  with  the  sudden  onset  of  typical  symptoms 
and  signs,  the  diagnosis  is  extremely  easy.  But  he  who  asserts  that 
the  diagnosis  of  foreign  body  in  the  air  passages  of  children  is 
always  easily  or  even  readily  made  has  had  little  experience.  It 
can  be  extremely  difficult  and  in  some  cases  impossible.  Besides 
a  careful  inquiry  into  the  history,  which  should  not  be  too  much 
relied  upon,  and  a  close  observation  of  the  symptoms,  ausculation 
over  the  windpipe  and  lungs,  and  percussion  of  the  chest  may  be 
useful.  The  whistling  of  the  air  in  passing  the  obstruction  may  for- 
tunately be  distinctly  located,  or  the  rattling  of  a  loose  body  up  and 
down  the  trachea  may  be  unmistakable ;  or  if  the  body  completely 
occlude  a  bronchus  a  portion  of  lung  will  be  silent.  When  the  body 
is  loose  in  the  trachea  the  intervals  between  the  spasmodic  attacks  of 
coughing  and  dyspnea  are  longer  than  when  it  is  within  the  larynx. 
When  lodged  in  a  bronchus  the  cough  is  less  spasmodic  than  when 
in  the  trachea  and  there  may  be,  though  not  always,  pain  in  the 
chest. 

Digital  exan- "nation  should  be  made  of  the  epiglottis  and 
pharynx.  Laryngoscopy  should  be  patiently  tried  with  local  or  even 
general  anesthesia.  As  a  matter  of  fact  it  seldom  succeeds  where 
other  methods  have  failed.  Diagnosis  by  direct  inspection  of  the 
larynx,  trachea  and  bronchi  by  the  method  of  Killian,  will  like- 
wise be  referred  to  under  treatment. 

Radiography  promises  much  in  these  cases,  and,  when  the  for- 
eign body  is  sufficiently  impenetrable  to  the  X-ray,  is  of  great 
service. 


SURGERY    OF   AIR   PASSAGES  4^3 

Prognosis. — Prognosis  is  always  doubtful.  This  is  a  serious 
accident  and  the  result  is  uncertain.  Each  case  must  be  judged  on 
its  own  features.  Much  depends  on  the  size  of  the  foreign  body,  the 
completeness  of  the  occlusion  its  causes,  its  shape  and  surface,  its 
consistency  and  its  point  of  lodgment.  If  not  of  a  shape  to  lacerate 
surrounding  structures,  if  not  of  a  size  to  obstruct  the  air  supply 
to  a  fatal  degree,  if  lodged  high  and  seen  early  before  inflamma- 
tion, the  prognosis  is  better  than  under  opposite  conditions.  If 
loose  in  the  trachea  it  is  better  than  if  lodged  in  a  bronchus.  A 
small,  smooth,  impervious  object  will  be  less  dangerous  than  one 
which  will  absorb  moisture  and  swell  without  dissolving  or  disin- 
tegrating. Bones  or  other  articles  which  either  lacerate  the  tissue 
or  convey  infection,  or  do  both,  are  especially  dangerous.  A  foreign 
body  may  be  removed  and  leave  behind  a  septic  inflammation  which 
may  prove  fatal,  .especially  if  it  have  extended  to  cellular  tissues.  As 
a  rule,  once  the  foreign  body  is  removed,  recovery  follows,  some- 
times even  in  conditions  apparently  desperate.  It  may  lodge  for  a 
time  where  no  symptoms  are  produced,  and  then  change  its  position 
and  cause  suffocation  or  occlude  a  bronchus  or  cause  pressure  and 
ulceration.    There  is  no  safety  until  removal  is  effected. 

I  shall  never  forget  my  first  case  of  foreign  body  in  the  larynx. 
A  girl  of  six  years  thought  she  had  drawn  into  her  larynx  a  piece 
of  hickory-nut  kernel.  She  was  brought  from  the  country  to  my 
clinic  at  the  dispensary.  There  was  partial  aphonia  and  dyspnea, 
but  it  was  quite  moderate.  I  placed  her  in  hospital,  intending  to 
operate.  But  a  distinguished  throat  specialist  and  the  senior  sur- 
geon, both  my  superiors  on  the  staff,  .examined  her  and  advised 
against  operation.  The  laryngologist,  on  several  occasions,  on  sev- 
eral days,  inspected  her  larynx  and  attempted  to  remove  the  for- 
eign body  with  laryngeal  forceps.  On  the  fourth  day  the  foreign 
body  shifted  its  position  and  dyspnea  became  extreme.  The  house 
doctor  hastily  summoned  aid.  I  was  first  to  arrive,  and  in  a  minute 
had  opened  the  larynx  and  extracted  the  nut  kernel,  and  the  girl 
breathed  easily.  But  it  was  her  last  breath.  She  was  exhausted. 
Timely  operation  would  have  saved  that  child. 

Treatment. — If  an  adult  is  at  hand  when  the  accident  happens, 
a  finger  passed  into  the  throat  may  hook  out  or  push  away  a  foreign 
body  caught  beneath  or  pressing  upon  the  epiglottis ;  or  by  inverting 
and  shaking  the  patient  or  slapping  him  forcibly  upon  the  thorax 
it  may  be  expelled  even  from  the  larynx  or  lower  in  the  air  passage. 
If,  in  spite  of  these  efforts,  immediate  suffocation  threatens,  the 
windpipe  must  be  opened  at  once,  a  cricolaryngotomy  or  cricotra- 
cheotomy  being  most  advisable  in  such  an  emergency.  If  the  symp- 
toms are  not  so  urgent,  the  patient  getting,  even  with  some  effort, 
enough  air  for  oxygenation,  or  if  after  a  paroxysm  of  coughing  and 


484  SURGICAL   DISEASES    OF    CHILDREN 

dyspnea  a  period  of  quiescence  takes  place,  preparations  for  thor- 
ough examination  and  for  operation  should  be  made  before  the 
patient  is  disturbed  by  any  manipulation,  change  of  position,  or 
medication.  It  is  true  that  a  repetition  of  the  inversion  and  slap- 
ping or  shaking,  or  the  exhibition  of  an  emetic,  as  a  hypodermic  of 
apomorphia,  or  a  dose  of  turpeth  mineral  or  of  ipecac,  might  dis- 
lodge and  expel  the  foreign  body ;  but  it  might,  instead,  cause  it  to 
change  its  position  to  some  point  producing  such  prompt  suffoca- 
tion that  instant  operative  interference  would  be  demanded.  After 
preparation  for  an  emergency  the  inversion  or  the  emetic  may  be 
tried.  If  unsuccessful  it  becomes  necessary  to  decide  upon  operative 
procedure,  either  by  an  endolaryngeal  or  an  external  method.  Intu- 
bation with  the  ordinary  tubes  is  not  applicable  to  this  class  of  cases. 
O'Dwyer's  foreign  body  tube  (Fig.  174),  short  and  with  wide  lumen, 
may  be  introduced  by  one  familiar  with  intubation.  By  holding  open 
the  larynx  it  may  facilitate  the  expulsion  during  coughing  or  the 
removal  by  laryngeal  forceps  of  any  body  not  too  large  for  the 
lumen  of  the  tube.  But  a  foreign  body  in  the  larynx  may  he  pushed 
farther  down  by  the  introduction  of  the  tube,  or,  if  it  be  quite  small 
and  lodged  in  the  ventricle,  may  be  imprisoned  there  by  the  tube. 

The  laryngoscopic  mirror  and  forceps  and  snares  of  various 
forms  have  long  been  employed,  and  in  fortunate  cases  will  suc- 
ceed. The  difficulty  of  using  them,  especially  in  infants  and  small 
children,  with  the  diminutive  anatomy  and  the  swelling  and  the 
mucous  secretion  that  are  often  present  in  these  cases,  bar  many 
general  surgeons  from  their  use ;  while  often  the  specialist  in 
laryngology  is  inclined  to  regard  this  method  of  endolaryngeal  work 
as  the  ultimate  resource  of  justifiable  surgical  art.  The  direct,  or 
Killian's  method,  has  the  advantage  in  the  hands  of  one  skilled  in 
its  technique,  but  is  liable  to  do  a  great  deal  more  harm  in  the  hands 
of  the  unskillful,  and,  like  the  laryngoscopic  procedures,  is  too 
often  baffled  by  the  small  size  of  the  parts  and  the  abundant  flow 
of  mucus,  which  obscures  the  view  and  prevents  effective  work. 
If  the  proper  instruments  are  to  be  had  and  the  surgeon  is  familiar 
with  their  use,  endolaryngeal  methods  should  be  tried  first. 

I  believe  that  bronchoscopy  by  Killian's  or  Jackson's  or  similar 
instruments  will  come  into  greater  prominence  in  the  near  future. 
Foreign  bodies  can  be  removed  even  from  children  and  infants  by 
this  method.  Upper  tracheoscopy  and  bronchoscopy  is  described 
substantially  as  follows,  by  Jackson :  Local  or  general  anesthesia 
may  be  used  even  in  children,  but  chloroform  is  used  unless  there  is  a 
positive  contra-indication.  The  patient  is  placed  horizontally  in  the 
dorsal  position,  with  the  head  extending  over  the  end  of  the  table 
and  supported  in  extreme  extension  by  an  assistant.  A  double 
bronchoscope  battery  is  used,  one  cord  being  attached  to  the  sep- 


SURGERY   OF   AIR    PASSAGES  485 

arable  speculum  and  the  other  to  the  bronchoscope.  The  operator 
slides  the  separable  speculum  down  over  the  dorsum  of  the  tongue 
until  the  epiglottis  comes  into  view.  Then  the  epiglottis  and  all 
the  tissues  attached  to  the  hyoid  bone  are  lifted  strongly  with  the 
point  of  the  separable  speculum,  not  using  the  upper  teeth  as  a  ful- 
crum. When  the  separable  speculum  is  in  a  position  with  its  axis 
corresponding  exactly  with  that  of  the  trachea,  the  depths  of  the 
latter  are  seen  below  the  vocal  cords.  The  bronchoscope  is  now  in- 
troduced through  the  separable  speculum  until  the  tube  mouth  is 
near,  but  does  not  touch  the  cords.  The  respiratory  movements  of 
the  cords  are  watched,  and  during  an  inspiration  the  bronchoscope  is 
pushed  through  into  the  trachea.  The  gag  is  then  inserted  and  the 
separable  speculum  is  removed,  leaving  the  bronchoscope  in  position 
in  the  trachea.  No  difficulty  is  encountered  unless  the  larynx  is 
abnormally  contracted  or  the  neck  is  made  rigid  by  adhesions  fol- 
lowing the  wearing  of  a  tracheotomy  canula.  If  there  is  bilateral 
abductor  paralysis,  so  that  the  cords  will  not  separate,  it  is  necessary 
to  push  the  bronchoscope  between  them.  In  such  cases  it  may  be 
easier  to  pass  the  bronchoscope  with  the  obturator  in  place,  as  this 
prevents  abrasion  of  the  mucosa  or  catching  the  tube-mouth  upon 
the  arytenoids. 

If  endolaryngeal  methods  fail  there  yet  remain  extra-laryngeal 
operations,  and  in  the  present  state  of  knowledge  and  practice  it  is 
probable  that  an  extra-laryngeal  operation  would  be  chosen  by  the 
majority  of  surgeons  throughout  the  country.  Among  these  one 
may  choose  thyrotomy,  cricothyrotomy,  cricotracheotomy,  or  trache- 
otomy below  the  isthmus.  For  a  discussion  of  operations  and  their 
technique  the  reader  is  referred  to  the  Chapter  on  Aeroporotomy. 

As  to  the  choice  between  supra-  and  infra-isthmian  operation 
in  a  case  of  foreign  body,  the  precise  location  of  which  in  the  air 
tubes  had  not  been  ascertained,  my  decision  would  be  in  favor  of 
opening  above  the  isthmus.  This  opening  would  include  the  cricoid 
cartilage  and  several  rings  of  the  trachea,  an  opening  large  enough 
for  the  exit  of  the  body.  Power  advises  that  the  opening  be  made 
below  the  isthmus.  This  might  be  well  in  a  large,  lean  child,  or  if 
the  body  were  lodged  in  a  bronchus  or  at  the  bifurcation.  But  if  its 
whereabouts  be  undetermined  the  lower  opening  is  farther  away 
from  the  possible  location  of  the  body  in  the  larynx.  In  the  young 
or  fat,  short-necked  child  the  greater  difficulty  of  the  infra-isthmian 
operation  is  not  to  be  courted  unless  there  is  to  be  an  advantage 
gained  by  so  doing.  The  incision-  in  the  windpipe  should  be  held 
open  by  sutures  either  attaching  it  to  the  skin  or  tied  together  behind 
the  neck. 

If  the  foreign  body  is  not  found  in  the  opening,  by  lowering  the 
patient's    shoulders    and    head    while    he    lies    ]M-one    and    inducing 


486  SURGICAL   DISEASES    OF   CHILDREN 

cough,  it  may  be  expelled.  Failing  in  this,  a  prohe,  or  better,  some- 
thing larger,  like  a  catheter,  as  Holmes  suggests,  should  be  passed 
upward  through  the  larynx  and  so  may  dislodge  it  into  the  throat. 
A  finger  in  the  mouth  at  the  same  time  should  ascertain  whether  it 
passes,  as  it  might  be  swallowed.  If  the  body  is  discovered  in  the 
larynx,  but  cannot  be  thrust  out  or  extracted  with  forceps,  the  inci- 
sion must  be  extended  upward  between  the  alae  of  the  thyroid  carti- 
lage, thus  exposing  all  within  the  larynx.  The  body  being  then 
removed  the  halves  of  the  cartilage  should  be  carefully  reunited 
by  sutures.  If  there  is  much  inflammation  a  tracheotomy  tube  had 
best  be  introduced  and  retained  for  a  few  days  or  until  the  laryn- 
gitis subsides.  If  the  body  is  not  encountered  in  the  larynx  a 
laryngeal  mirror  or  a  Killian's  or  Jackson's  tube  may  discover  it 
below  the  opening  in  the  trachea  or  a  bronchus,  whence  it  may  be 
removed  by  forceps.  If  these  instruments  are  not  to  be  had  a 
somewhat  flexible  probe,  a  loop  of  "  stiffish  copper  wire  bent  near 
the  closed  end  should  be  passed  down"  (Owen),  hoping  to  snare 
and  withdraw  the  substance. 

If  the  body  cannot  be  removed  the  wound  should  be  held 
Open  by  the  sutures,  dressed  with  a  covering  of  several  layers  of 
gauze,  and  the  child  be  kept  a  good  part  of  the  time  lying  prone  so 
that  the  discharges  and  perchance  the  foreign  body  may  find  exit. 
In  this  as  in  all  cases  of  external  aeroporotomy  the  air  of  the  room 
should  be  moistened  and  maintained  warm  and  equable.  At  the 
daily  visits  of  the  surgeon,  if  the  condition  of  the  child  and  of  the 
wound  permit,  efforts  to  locate  or  to  remove  the  foreign  body 
may  be  renewed.  Inversion  of  the  patient  during  the  attacks  of 
coughing  excited  by  the  dressing  may  aid  the  expulsion,  as  illus- 
trated by  one  of  my  cases.  A  child  of  less  than  two  years,  while 
playing  with  shelled  corn,  was  attacked  suddenly  with  violent  prox- 
ysmal  coughing  which  gradually  subsided.  During  the  occasional 
fits  of  coughing  a  foreign  body  was  heard  to  rattle  in  the  trachea. 
But  on  tracheotomy  I  could  not  find  it,  and  all  efforts  failed  to  dis- 
lodge it.  I  held  the  tracheal  wound  open  by  a  suture  at  each  side, 
tied  around  the  neck,  and  left  two  of  my  students  to  watch  the 
case.  At  my  third  visit,  on  inverting  the  patient  during  a  fit  of 
coughing  and  giving  him  a  slap  on  the  back,  the  kernel  of  corn  was 
dislodged,  came  into  the  tracheal  wound  and  was  instantly  removed. 

MEMBRANOUS   LARYNGITIS    (MEMBRANOUS    CROUP:  DIPH- 
THERITIC   CROUP:  TRUE  CROUP) 

Innumerable  .essays  have  been  written  and  discussions  held  in 
times  past  upon  the  questions  of  the  identity  of  membranous  croup 
and  diphtheria,  and  upon  the  "  constitutional  "  or  "  local  "  nature 
of  the  disease  or  diseases.    The  discovery,  in  1884,  of  a  small  non- 


SURGERY   OF   AIR   PASSAGES  487 

motile,  slightly  curved  bacillus  with  one  large  end,  which  have  come 
to  be  so  well  known  by  the  names  of  Loefifier  and  of  Klebs,  and  the 
subsequent  labors  of  Roux  and  Yersin,  and  of  Sidney  Martin  and 
others,  have  solved  a  great  many  of  the  problems  before  so  puzzling. 
We  know  that  the  two  diseases  are  identical  in  origin  and  that 
although  at  first  local,  ferments  and  toxines  resulting  from  the 
local  disease  profoundly  affect  the  blood,  the  nerves  and  certain 
internal  organs.  (See  Section  on  Diphtheria.)  We  are  aware  that 
organisms  other  than  the  diphtheria  bacillus,  usually  a  strep- 
tococcus, and  even  inflammations  resulting  from  scalds  or  chemi- 
cal burns,  especially  when  following  another  specific  infection,  are 
capable  of  producing  one  of  the  peculiar  features  of  diphtheritic 
laryngitis — the  false  membrane.  Yet  clinical  as  well  as  bacterio- 
logical experience  has  taught  us  that  it  is  best  to  consider  all  mem- 
branous inflammations  of  the  larynx  diphtheria,  until  they  are 
proven  to  be  something  else.  The  pathology  and  the  lesions  of 
diphtheria  have  been  discussed  under  another  section.  It  remains 
to  be  said,  however,  that  the  situation  of  the  local  lesion  has  much 
to  do  with  the  resultant  remote  or  constitutional  effects.  Mem- 
branous diphtheria  does  not  present  the  enlargement  of  the  lymph- 
nodes,  the  profound  toxemia,  the  soft  pulse,  albuminuria,  the  de- 
generations of  blood,  of  heart  muscle,  kidneys,  nerves,  and  other 
structures  that  accompany  the  pharyngeal  or  naso-pharyngeal  form 
of  diphtheria.  For  the  absorbents  of  the  laryngeal  mucous  lining 
are  less  numerous  and  active  than  those  of  the  larynx,  or  the  me- 
chanical obstruction  to  respiration  may  kill  the  patient  before  the 
toxines  have  had  time  to  be  developed  and  absorbed.  It  is  this  me- 
chanical obstruction  or  stenosis  occasioned  by  the  localization  of  the 
disease  in  the  air  passage  that  makes  diphtheritic  laryngitis  one  of 
the  most  important  surgical  ailments  of  childhood. 

Symptoms. — The  onset  is  usually  less  abrupt,  more  indefinite 
and  milder  than  that  of  catarrhal  or  false  croup,  which  otherwise 
it  much  resembles.  Slight  stridor,  hoarseness,  cough,  moderate 
fever,  excited  manner  and  a  quickened  pulse — these  are  the  appar- 
ently insignificant  symptoms.  There  is  only  one  characteristic  that 
might  arouse  suspicion  on  the  first  or  even  the  second  day  of  the 
disease,  even  if  the  child  had  been  previously  quite  w.ell,  namely, 
the  steady  and  persistent  progress  of  the  symptoms.  By  the  second, 
or  at  most  the  third  or  fourth  day,  the  hoarseness  merges  into 
suppression  of  the  voice,  the  slight  stridor  becomes  more  hissing 
and  is  accompanied  by  dyspnea,  the  excitement  has  become  restless- 
ness, the  degree  or  two  of  fever  has  increased  to  three  or  four, 
and  this  has  gone  on  regardless  of  treatment  that  would  relieve 
ordinary  croup.  Even  an  emetic  produces  only  temporary  change, 
if  any.     The  disease  goes  right  on.     The  voice  is  usually  entirely 


488  SURGICAL   DISEASES    OF   CHILDREN 

suppressed.  The  dyspnea  becomes  extreme.  Expiration  as  well  as 
inspiration  are  forced,  hissing  and  prolonged.  At  each  inspiration 
there  is  a  deep  recession  above  the  sternum  and  clavicles  and  at  the 
epigastrium,  all  the  accessory  muscles  of  respiration  being  required 
to  force  the  air  in  and  out  through  the  narrowed  larynx.  The  skin 
is  covered  with  perspiration.  The  restlessness  has  now  become 
anxiety,  or  even  terror.  The  child  tosses  about  and  turns  in  every 
direction  for  more  air,  and  by  looks  and  actions  appeals  to  those 
about  for  help.  The  heart  for  a  time  labors  violently.  The  lips 
and  finger-tips  may  be  cyanotic.  As  the  heart  weakens  and  as  the 
blood  collects  in  the  chest,  there  may  be  pallor  instead  of  cyanosis. 
Stupor  supervenes,  and  finally  coma,  sometimes  convulsions,  and 
death.  Occasionally  the  temperature  runs  up  rapidly  in  the  last 
few  hours  of  life  similarly  to  the  fever  of  the  convulsive  state,  reach- 
ing 105  or  106  degrees  F.  At  any  stage  of  the  disease  attacks  of 
spasmodic  dyspnea  may  be  added  to  the  continuous  difficulty  of 
respiration.  Or  suddenly  increased  obstruction  or  heart  failure 
may  terminate  the  life  quite  unexpectedly.  This  is  particularly 
true  of  croup  following  pharyngeal  or  nasal  diphtheria.  The  whole 
course  will  vary  from  thirty-six  or  forty-eight  hours  to  a  week.  As 
a  rule  the  younger  the  patient  the  sooner  he  will  succumb.  The 
great  majority  of  the  cases  of  all  ages  to  which  I  have  been  sum- 
moned in  consultation,  have  been  on  the  fourth  or  fifth  day  of  the 
disease.  And  more  of  my  intubations  for  desperate  laryngeal  sten- 
osis, for  which  the  attending  physician  had  usually  exhausted  medi- 
cal resources,  were  made  on  the  fifth  day  of  the  disease  than  on  any 
other  day.  In  some  cases  the  disease  extends  rapidly  to  the  bronchi 
or  lungs  before  the  larynx  becomes  occluded.  The  foregoing  is 
a  picture  of  the  ordinary  course  of  the  disease  when  untreated. 
Under  treatment,  and  in  come  cases  without  treatment,  the  pseudo- 
membrane  becomes  detached,  and  is  coughed  out,  in  patches  of 
the  size  of  a  finger-nail  or  larger,  or  in  casts  of  the  larynx  and  tra- 
chea ;  and  rarely,  in  casts  of  larynx,  trachea,  and  bronchise.  Fig. 
171  shows  the  most  complete  one  I  have  ever  had  from  a  live 
patient.  The  patient  from  whom  this  membrane  came  during 
intubation,  finally  died;  but  the  ejection  of  the  false  membrane 
often  clears  the  larynx  and  proves  the  point  of  turning  toward 
recovery ;  or  the  membrane  may  form  again. 

Prognosis. — There  is  probably  no  disease,  unless  it  is  smallpox, 
in  which  one  generation  has  been  permitted  to  witness  such  a  great 
change  in  the  prognosis.  In  my  own  earlier  experience,  previous 
to  O'Dwyer's  splendid  achievement,  cases  of  diphtheritic  croup  nearly 
all  died.  We  could  save  a  few  of  them  by  sustaining  treatment,  the 
heroic  use  of  mercury,  stimulants,  the  doubtful  aid  of  the  rest  of  the 
pharmacopea,    and    an    occasional    laryngo-tracheotomy.      But    the 


SURGERY   OF   AIR    PASSAGES 


489 


mortality  was  probably  80  or  90  per  cent. 
Parents  would  seldom  consent  to  tracheot- 
omy because  it  is  a  cutting  operation  and 
the  surgeon  could  not  promise  certain  re- 
covery as  a  result.  After  we  had  intuba- 
tion, with  that  and  mercury  (besides 
whisky,  iron,  chloral,  strychnine,  lime- 
steam,  antiseptic  vapors  and  the  rest),  I 
could  save  about  one-third  of  my  desper- 
ate cases,  which  otherwise  would  almost 
certainly  have  died.  Since  the  advent  of 
antitoxin,  with  operative  measures  and 
good  management,  the  figures  are  reversed 
and  one  looks  for  the  recovery  of  80  or 
90  per  cent,  of  his  personal  and  consulta- 
tion cases. 

Diagnosis. — The  diagnosis  is  usually 
not  difficult.  Merely  looking  at  a  patient 
and  listening  to  the  sound  of  his  labored 
breathing  would  not  inform  the  observer 
what  form  of  dyspnea  he  had  met.  If  he 
noted  the  suppressed  voice  he  would 
locate  the  trouble  in  the  larynx.  But  it 
might  be  chronic  laryngitis,  or  tumor  or 
foreign  body.  The  history  would  exclude 
all  theS'C.  Foreign  body  would  have  a 
history  of  sudden  onset  and  the  others  of 
chronic  course,  and  none  of  them  have 
fever.  Spasmodic  or  catarrhal  croup  is 
hoarse  but  not  voiceless ;  expiration  is 
usually  easier  than  inspiration,  and  it  is 
apt  to  come  suddenly  and  not  to  grow 
worse  persistently  when  treated.  Retro- 
pharyngeal abscess  does  not  usually  sup- 
press the  voice,  but  it  alters  its  tone  to  a 
hollow  or  quacking  sound ;  and  the  ab- 
scess swelling  may  be  found  on  inspection 
or  palpation ;  and  it  has  a  history  of  a 
week  or  two.  Membranous  laryngitis 
does  not  invariably  suppress  the  voice. 
The  breathing  of  capillary  bronchitis  or 
broncho-pneumonia  more  nearly  than  any 
other  disease  resembles  that  of  true  croup. 
But  there  is  not  the  recession  above  and 
below     the     thorax,     nor    the     laryngeal 


Fig.  171.  Specimen  of 
diphtheritic  mem- 
BRANE coughed  out 
during   intubation. 


490  SURGICAL   DISEASES    OF   CHILDREN 

stridor,  and  the  physical  signs  can  be  found  in  the  chest.  A  diag- 
nosis of  diphtheritic  laryngitis  is  made  if  the  illness  is  of  two  or 
three  days'  duration  with  severe,  persistent  and  increasing  dyspnea 
and  suppressed  voice. 

Treatment. — The  patient,  if  under  two  years,  should  have  from 
2000  to  5000  units  of  antitoxin.  If  in  twelve  hours  no  improvement 
or  insufficient  improvement  has  occurred,  another  dose  of  5000 
may  be  given.  If  the  patient  is  over  two  years,  4000  to  7000  units 
may  he  given  at  first,  or  if  the  case  is  severe,  8000  or  10,000  units. 
When  antitoxin  was  first  introduced,  and  for  some  time  thereafter, 
we  got  the  same  effect  from  2000  units  that  we  now  get  from  4000. 
After  a  time  the  manufacturers  apparently  measured  the  dose  more 
strictly  or  changed  the  serum,  for  we  found  it  necessary  to  give 
more  units.  By  this  time  the  innocuousness  of  the  serum  had  been 
demonstrated,  and  some  enthusiastic  users  of  antitoxin  advocated 
enormous  doses,  even  scores  of  thousands  of  units.  I  have  never 
found  that  necessary,  or  useful.  If  a  proper  dose  is  given  at  first,  it 
is  not  necessary  to  repeat  it  in  six  to  eight  hours.  Often  a  period 
of  twelve  to  fourteen  hours  is  required  before  effects  are  manifested. 
I  believe  that  when  a  second  dose  is  given  in  six  hours  the  effects 
noticed  six  hours  afterward  are  those  of  the  first  dose.  The  rule 
should  be  to  give  an  adequate  dose  early,  so  that  it  need  not  be 
repeated.  The  age  of  the  child  should  receive  some  consideration 
in  measuring  the  dose,  but  the  main  thing  to  be  considered  is  the 
severity  of  the  attack.  Mild  cases  at  any  age  will  get  well  if  3000 
to  5000  units  or  less  are  given  early  in  the  disease.  A  second  dose 
will  not  be  necessary.  Most  cases  of  diphtheria  get  well  with  4000 
to  8000  or  10,000  units.  It  is  very  exceptional  that  12,000  or  15,000 
units  is  necessary.  Those  cases  that  are  said  to  require  30,000  and 
50,000  and  70,000  units  are  not  pure  diphtheria.  One  need  not  deny 
that  the  large  doses  of  serum  are  of  any  benefit  in  such  cases.  But 
their  effect  may  be  rather  as  serum  than  as  diphtheria  antitoxin. 
Injections  of  normal  salt  solution  also-  benefit  many  cases,  of  vari- 
ous kinds.  "  Early  "  in  the  disease  means  on  the  first  day  that  a 
clinical  diagnosis  can  be  made.  The  bacteriological  diagnosis  should 
be  made  but  not  be  waited  for  before  giving  the  antitoxin. 

In  the  absence  of  antitoxin,  there  is  no  remedy  equal  to  mer- 
cury. One  has  often  given  a  child  of  five  or  six  years  a  grain  of 
calomel  or  gray  powder  every  hour  until  twenty  or  thirty  doses 
were  taken.  Dover's  powder  sufficient  to  control  excessive  action 
of  the  bowels  was  used  in  conjunction.  The  latter  also  relieved  the 
breathing  and  promoted  the  loosening  of  the  membrane.  Other  seda- 
tive or  stimulating  expectorants  were  used.  A  better  way  to  use  mer- 
cury in  diphtherial  laryngitis  is  by  sublimation  as  introduced  by 
Corbin.     The  apparatus  is  as  simple  as  possible.     A  tent  is  made 


SURGERY   OF   AIR    PASSAGES  491 

over  the  bed.  Under  the  tent  a  spirit  lamp  is  placed  in  the  bottom 
of  a  vessel.  A  strip  of  tin  or  sheet  iron  is  laid  across  the  top  of  the 
vessel  just  above  the  flame  of  the  lamp.  A  dose  of  five  to  ten  grains 
of  calomel  is  placed  upon  the  sheet  of  metal  and  sublimed.  This 
dose  is  repeated  every  two  hours  for  the  first  two  days  and  nights ; 
or  in  urgent  cases  the  intervals  may  be  shortened  to  a  half  hour  for 
four  or  five  times.  Or  a  smaller  quantity  may  be  used  at  short 
intervals.  On  the  third  day  the  intervals  are  prolonged.  (Rotc'h, 
jMorse  and  many  others.) 

The  mouth  should  be  washed  after  each  dose.  It  is  sur- 
prising how  much  mercury  a  diphtheria  patient  will  take  with 
marked  benefit  and  no  bad  symptom.  Nurse  or  parent  remaining 
under  the  tent  would  be  salivated.  When  antitoxin  is  used  mercury 
in  heroic  doses  is  neither  necessary  nor  so  well  tolerated.  Mercury 
was  the  best,  in  fact  the  only  valuable  remedy  we  had,  before  anti- 
toxin. The  nutrition  of  the  patient  should  be  well  kept  up  by  care- 
ful feeding  of  easily  assimilated  foods.  Stimulants,  of  which  some 
form  of  alcohol  is  best,  should  be  used  as  needed ;  though  the  enor- 
mous amounts  of  alcohol  that  can  be  taken  with  benefit  by  a  child 
with  phar}'ngeal  diphtheria  are  not  needed  in  the  laryngeal  form. 
Strychnia  is  a  good  stimulant  in  these  cases;  also  camphor  (in  oil 
hypodermatically)  and  carbonate  of  ammonia.  Oxygen  is  a  great 
help  if  it  can  be  procured  for  use  until  the  intubator  comes.  Emetics 
in  laryngeal  diphtheria  have  been  abused.  Occasionally  they  give 
temporary  relief,  and  sometimes,  when  the  membranes  have  loos- 
ened, they  are  cast  off  in  the  act  of  vomiting.  But  the  repeated  use 
of  emetics  does  no  good,  but  a  great  deal  of  harm  by  exhausting  the 
patient  and  disordering  his  stomach. 

Inhalation  of  steam,  steam  from  slaking  lime,  or  other  alkaline 
vapors,  while  they  have  no  appreciable  effect  in  dissolving  the  mem- 
brane, render  the  air  more  agreeable  to  the  air  passage  and  by  this 
soothing  efi^ect  lessen  the  tendency  to  spasmodic  dyspnea.  Moisture 
prevents  drying  of  the  secretions  and  parching  of  the  mucous  lin- 
ings caused  by  the  rapid  breathing  of  the  feverish  patient.  The  old 
formula  of  J.  Lewis  Smith  was  composed  of  an  ounce  each  of  car- 
bolic acid  and  eucalyptol  with  turpentine  to  make  a  pint.  Of  this  a 
tablespoon ful  in  a  pint  of  water  is  kept  simmering.  It  is  usually 
grateful  to  the  patient  and  has  some  value  as  an  antiseptic ;  not  prob- 
ably having  any  power  against  the  Klebs-Loeffler  bacillus,  but 
against  other  organisms  apt  to  be  present  in  mixed  infections.  The 
formula  is  improved  both  in  quality  and  odor  by  adding  a  drachm 
of  oil  of  cinnamon  or  a  drachm  of  menthol  or  both.  But  nothing 
should  be  allowed  to  attract  our  attention  away  from  antitoxin  and 
aeroporotomy.  Other  treatment  is  useful  in  cases  of  mixed  infec- 
tion.   The  digestive  ferments  and  all  so-called  solvents  of  false  mem- 


492  SURGICAL   DISEASES    OF   CHILDREN 

branes  are  useless.  The  naso-pharynx  should  be  kept  clean  and 
clear  by  irrigation  with  warm  normal  salt  solutions  or  borax  and 
bicarbonate  of  soda  solutions  of  equal  strength,  or  boric  acid  five 
per  cent.,  or  any  other  mild  antiseptic  wash.  A  spray  may  be  used 
in  selected  cases,  but  is  not  as  efficient  as  irrigation.  Some  children 
can  gargle  with  advantage.  Irrigation,  sprays  and  gargles  are 
usually  discontinued  if  the  case  is  intubated.  But  mild  ones  may 
be  used  with  the  child  recumbent.  Certainly  no  astringent,  or  any 
coagulating  solution  like  hydrogen  peroxide  should  be  used  in  the 
presence  of  an  intubation  tube  for  fear  of  causing  an  obstruction. 
Exteral  applications  have  no  effect  upon  the  diphtheritic  process, 
but  cold,  applied  with  the  ice-collar,  may  limit  inflammation ;  and  in 
glandular  enlargements  with  cellulitis,  due  to  streptococcus  infec- 
tion, which  sometimes  complicates  diphtheria,  the  following  prescrip- 
tion or  something  like  it  (Park)  may  be  applied:  Resorcin  (or 
naphthaline),  5;  ichthyol,  5;  mercurial  ointment,  40;  lanolin,  50. 
The  skin  is  anointed  with  this  and  covered  with  oil  silk  and  a  light 
bandage. 

Indications  for  Aeroporotomy. — The  rules  usually  given  for 
deciding  when  it  is  necessary  to  resort  to  some  operation  to  let  more 
air  into  the  lungs  are  as  follows :  When  the  dyspnea  increases  or 
continues  in  spite  of  other  measures  for  its  relief.  When  the  ac- 
cessory muscles  of  respiration  are  at  work,  and  the  soft  parts  above 
and  belov/  the  thorax  recede  on  inspiration.  When  the  vesicular 
murmur  cannot  be  detected  in  the  bases  of  the  lungs,  etc.,  etc.  As  a 
matter  of  fact  the  laryngeal  stridor  is  often  so  noisy  that  one  can 
hear  nothing  else.  When  the  temperature  begins  to  run  high. 
Some  would  advise  to  defer  until  cyanosis  threatens  carbonic  acid 
poisoning.  But  every  man  with  experience  knows  that  cases  often 
die  without  cyanosis ;  or  that  cyanosis  may  be  so  closely  followed 
by  death  that  there  is  no  time  to  summon  aid  or  to  operate.  There  is 
really  only  one  rule  for  deciding  when  to  operate.  Mr.  Owen 
has  well  stated  it  in  his  indication  for  tracheotomy :  "  When  an  in- 
sufficient amount  of  air  is  entering  the  lungs."  Why  physicians 
will  wait,  and  wait,  allowing  a  child  to  suffer  and  struggle  for  air, 
while  the  lungs  are  becoming  engorged  and  the  heart  exhausted, 
when  relief  is  so  easily  employed  and  so  prompt  in  its  effects,  is  hard 
to  understand.  Yet  one  has  often  been  summoned  at  the  eleventh 
hour  after  a  physician  had  been  in  attendance  two  or  three  days, 
and  found  the  patient  moribund ;  and  in  several  cases  found  the 
patient  had  ceased  to  breathe  and  was  thought  dead  by  the  friends, 
and  even  by  the  physician.  But  prompt  operation  and  artificial 
respiration  sometimes  saved  him.  It  is  criminal  to  delay  and  incur 
such  chances.  If  medical  means  have  been  employed  and  still  "  an 
insufficient  amount  of  air  is  entering  the  lungs "  it  is  time  for 
operative  measures. 


SURGERY    OF   AIR    PASSAGES  493 


AiEROPOROTOMY 


Aeroporotomy  includes  all  the  operations  for  opening  the  air 
passage.     (Kelley,  Cleve.  Med.  Gazette,  May,  1896.) 

It  is  most  frequently  demanded  for  the  stenosis  caused  by 
laryngeal  diphtheria,  yet  tumors  of  the  larynx,  edema  of  the  larynx 
from  various  causes,  or  foreign  bodies  in  the  air  passage,  or  bloody 
operations  of  the  mouth  or  throat  or  larynx,  may  call  for  aero- 
porotomy in  one  of  its  varieties,  and  the  surgeon  must  decide  which 
of  several  procedures  is  best  adapted  to  meet  the  condition.  Aero- 
porotomy is  either  internal  or  external.  The  internal  operation 
consists  in  intubation  of  the  larynx.  The  external  is  either  supra- 
isthmian  or  infra-isthmian,  that  is,  either  above  or  below  the  isthmus 
of  the  thyroid  gland.  The  supra-isthmian  operation  (sometimes 
called  the  "superior"  operation),  or  supra-glandular,  may  be  a 
laryngotomy,  in  which  only  the  larynx  is  opened ;  or  it  may  be  a 
laryngo-tracheotomy  (Bayer),  often  called  a  crico-tracheotomy 
(Hueter),  in  which  the  cricoid  cartilage  and  the  first  two  or  three 
rings  of  the  trachea  are  divided.  The  infra-isthmian  operation 
(called  by  some  the  "  inferior  "  or  infra-glandular  operation)  is  a 
tracheotomy.  Each  of  these  operations  will  be  described  and  its 
special  adaptations  pointed  out. 

Intubation. — Doubtless  many  practitioners  had,  like  the  writer, 
acting  upon  the  impulse  to  afford  at  least  temporary  relief,  cathe- 
terized  the  larynx  of  the  child  suffocating  with  diphtheritic  laryn- 
geal stenosis,  before  we  had  any  knowledge  of  intubation  as  it  is 
understood  and  practiced  to-day.  But  Bouchut  of  Paris,  in  1858, 
conceived  the  idea  of  introducing  a  metallic  tube  which  should 
be  left  in  position  in  the  larynx  and  through  which  the  patient  might 
breathe.  The  tube  of  Bouchut  was  like  a  small  open-end  thimble 
placed  in  the  top  of  the  larynx.  The  tube  had  a  silk  thread  attached 
which  was  brought  out  at  the  corner  of  the  mouth,  and  by  which 
the  tube  could  subsequently  be  removed.  Bouchut  published  seven 
cases  in  which  he  had  employed  his  tubage  in  laryngeal  diphtheria, 
with  relief  of  the  dyspnea.  The  Paris  Academy  of  Medicine  ap- 
pointed a  committee,  of  which  Trousseau  was  chairman,  to  investi- 
gate the  new  operation.  Trousseau,  who  had  revived  and  popular- 
ized tracheotomy,  was  at  the  height  of  his  influence ;  and  this  new 
procedure,  which  was  proposed  to  substitute  tracheotomy,  was  pro- 
nounced impracticable,  and  therefore  unjustifiable.  This  prevented 
Bouchut  from  continuing  his  experimental  labors  and  probably 
deprived  French  surgery  of  the  honor  of  presenting  to  the  pro- 
fession and  to  the  world  a  new  and  successful  life-saving  operation. 
This  honor  was  reserved  for  America.  In  1880  Dr.  Joseph  O'Dwyer 
began  his  experimental  study  of  the  problem.  He  studied  the  anat- 
omy of  the  larynx  and  the  pathological  anatomy  of  the  disease  at 


494  SURGICAL   DISEASES    OF   CHILDREN 

the  New  York  Foundling  Asylum.  He  was  gifted  with  a  talent 
for  patient  investigation  and  with  mechanical  ingenuity,  and  when 
he  had  perfected  his  instruments  and  his  operation  he  had  remark- 
able results.  He  presented  them  to  a  profession  far  more  receptive 
and  progressive  than  the  French  Academy  of  fifty  years  ago. 
Intubation  became  rapidly  established  in  the  United  States,  thou- 
sands of  successful  cases  being  reported  within  a  few  years  of  its 
introduction.  It  is  probable  that  history  affords  no  example  of  an 
equally  valuable  surgical  procedure  with  the  necessary  instruments 
for  performing  it,  being  so  nearly  perfected  by  one  man,  and  of  its 
being  so  quickly  recognized  and  rapidly  adopted  by  an  appreciative 
profession.  It  is  also  probable  that  no  other  operation  in  a  given 
length  of  time  has  indisputably  saved  so  many  lives.  In  Europe 
intubation  won  its  way  far  more  slowly  and  even  yet  is  not  employed 
nearly  so  often  as  with  us.  But  there  can  be  no  doubt  in  the  minds 
of  those  acquainted  with  both  external  operations  and  intubation  in 
laryngeal  diphtheria  what  the  final  verdict  of  the  profession  over 
the  whole  world  will  be.  Intubation  will  be  the  primary  operation 
of  universal  choice  in  all  but  a  comparatively  few  cases  in  which 
a  mass  of  membrane  is  located  too  low  for  the  intubation  tube,  or 
in  which  for  some  unusual  reason  it  is  impossible  to  introduce  the 
tube.  In  comparing  intubation  and  tracheotomy  it  may  be  said  that 
neither  operation  precludes  the  other ;  and  that  either  may  possibly 
require  the  other  in  the  sequellge  which  occasionally  follow. 

The  advantages  of  intubation  over  laryngo-tracheotomy  are 
these :  The  consent  of  the  parents  to  operation  can  usually  be  ob- 
tained because  there  is  no  cutting.  Intubation  relieves  the  dyspnea 
quite  as  certainly  and  completely  when  the  larynx  is  the  seat  of 
the  stenosis  as  does  tracheotomy. 

The  operation  involves  no  danger  from  hemorrhage  and  com- 
paratively none  from  shock. 

No  anesthetic  is  necessary,  therefore  that  danger  is  avoided ; 
and  also  no  anesthetist  is  required. 

No  skilled  assistant  is  required. 

The  inspired  air  passes  through  the  natural  channels  and  is 
thereby  warmed  and  moistened. 

The  air  current  ventilates  the  posterior  nares,  which  otherwise 
become  more  foul  and  poisonous. 

The  patient  can  cough  more  forcibly  and  expel  tenacious  mucus 
better  than  through  a  much  larger  tracheal  wound. 

There  is  no  wound  to  become  infected  by  diphtheritic  or  pyo- 
genic organisms.  There  is  no  danger  of  emphysema  of  cellular  tis- 
sues ;  and  no  scar. 

The  after-care  is  very  simple,  requiring  no  trained  attendant. 

There  is  less  likelihood  of  difficulty  in  dispensing  with  the 
intubation  tube  than  with  the  tracheotomy  tube. 


SURGERY   OF   AIR   PASSAGES 


495 


The  disadvantages  of  intubation  are :  There  is  a  possible  danger 
of  pushing  loose  membrane  before  the  tube  and  thus  blocking  the 
air  passage ;  or  of  passing  the  tube  between  the  false  membrane  and 
the  wall  of  the  windpipe.  Either  of  these  accidents  may  happen  also 
in  tracheotomy. 

Sudden  inhibition  of  respiration  from  irritation  through  the 
recurrent  laryngeal  nerve.  This  is  theoretically  correct,  but  very 
seldom  occurs  in  practice. 

The  tube  may  become  occluded  suddenly  by  a  piece  of  mem- 


FiG.     172.      Set    of    O'Dwyer's    Intubation    Instruments.      Mouth   gag, 
tubes  graduated  sizes,  gauge,  obturators,  introducer,  and  extractor. 


brane  or  by  tough  mucus,  and  suffocate  the  patient,  or  it  may  require 
that  the  tube  be  removed  and  cleared.  The  same  thing  may  happen 
with  a  tracheotomy  tube. 

The  trachea  may  be  obstructed  by  false  membrane  below  the 
reach  of  the  intubation  tube. 

The  advantages  of  the  external  operation  are :  It  opens  the  air 
passage  at  a  lower  point  and  may  thereby  clear  a  lower  obstruction. 

It  allows  the  removal  of  loose  membranes  within  reach  of  the 
opening. 

Notwithstanding  that  innumerable  efforts  have  been  made  by 
many  different  men  to  improve  O'Dwyer's  instruments,  and  numer- 
ous modifications  have  been  introduced,  they  are  still  accepted  as  the 


496 


SURGICAL   DISEASES    OF   CHILDREN 


best  models  by  the  majority  of  experienced  operators.  The  instru- 
ments consist  of  a  set  of  six  tubes  ranging  in  length  from  i  9-16 
inches  to  2  11- 16  inches  and  thick  in  proportion,  designed  to  fit  a 
child  of  any  age  from  one  year  or  less  up  to  puberty.  The  tubes  are 
shown  in  Fig.  172.  They  were  formerly  made  of  metal ;  but  that 
plan  was  discarded  in  favor  of  hard  rubber,  metal-lined.  This  does 
not  become  encrusted  with  lime-salts  like  the  metal,  and  is  lighter. 
The  opening  through  the  tube  is  oval  in  form,  being  longest  antero 
posteriorly.  The  upper  and  lower  portions  of  the  shaft  of  the  tube 
are  of  the  same  oval  shape,  but  enlarge  toward  the  center  of  the 
tube,  which  is  almost  cylindrical.    The  large  head  at  the  top  of  the 

tube  is  somewhat  quadrangular, 
one  angle  projecting  posteriorly, 
so  that  when  placed  in  the  larynx 
it  rests  between  the  arytenoid 
cartilages.  The  anterior  angle 
is  beveled  off,  so  that  the  epi- 
glottis can  better  descend  over 
the  top  of  the  tube.  The  head 
of  the  tube  is  well  rounded  be- 
neath, to  rest  upon  the  inferior 
ventricular  bands.  The  neck 
just  below  the  head  is  quite  nar- 
row laterally  where  it  passes 
between  the  true  vocal  cords, 
while  the  bulging  center  of  the 
shaft  being  below  the  cords  aids 
in  holding  the  tube  in  position 
during  coughing.  The  lower 
end  of  the  tube,  especially  its 
anterior  edge,  has  a  thickish 
rounded  edge  to  avoid  abrasion  of  the  mucous  lining,  not  only  in 
the  act  of  introducing  the  tube,  but  in  its  rising  and  falling  at 
every  act  of  deglutition.  Through  one  margin  of  the  head  of 
the  tube  is  a  small  hole  or  eyelet.  Through  this  hole  a  braided 
silk  thread  is  passed,  and,  its  ends  being  tied  together,  forms  a 
loop  by  which  the  tube  could  be  recovered,  if  by  chance  the  oper- 
ator were  to  pass  the  tube  into  the  esophagus  instead  of  the  larynx, 
or  by  which  the  tube  could  be  instantly  withdrawn  if  obstruction 
follow  its  introduction.  Tubes  are  sometimes  "  built  up "  for 
granulation  tissue  (Fig.  173,  i.,  ii.,  and  iii.),  and  are  useful  in  cases 
of  prolonged  intubation.  There  is  also  a  foreign  body  tube,  short 
and  with  wide  lumen.     (Fig.  174.) 

The  introducing  instrument  is  seen  in  Fig.  175.     It  consists  of 
a  handle  to  which  is  attached  a  shaft  and  obturator  of  a  size  to  fit 


1.  11.  111. 

Fig.    173.     "  Built  up  "   tubes   use- 
ful  FOR    GRANULATION    TISSUE^    and 

in  cases  of  retained  tube. 


SURGERY   OF  AIR   PASSAGES 


497. 


each  tube.  The  obturator  fits  the  kimen  of  the  tube  and  plugs  its 
lower  openmg  with  a  bulbous,  rounded  end.  It  is  just  tightly  enough 
engaged  in  the  tube  to  retain  the  latter  until  it  is  detached  by  a  push 
of  the  thumb  upon  the  button  placed  on  the  upper  side  of  the  handle. 


Fig.     174.      Foreign-body     Fig.  175.  Introducer  with  Fig.   176.     The  Ex- 
tube,  AND  introducer.  TUBE,    threaded.      An  obtu-  tractor. 

rater,  detached. 

The  extractor  (Fig.  176)  is  a  handle  having  a  shaft  curved  at 
right  angles  like  the  introducer  with  the  obturator.  At  the  lower 
extremity  of  the  curved  portion  are  two  small  beak-like  blades,  which 
are  made  to  separate  by  thumb  pressure  on  a  lever  at  the  handle. 
The  beaks  are  introduced  closed  into  the  top  of  the  opening  in 
the  tube,  and  when  expanded  they  impinge  on  its  interior  strongly 
enough  to  withdraw  the  tube  from  the  larynx. 

The  mouth  gag  is  shown  in  Fig.  177.     The  metal  ring  recom- 


498 


SURGICAL   DISEASES    OF   CHILDREN 


mended  by  some  instead  of  a  mouth  gag-,  designed  to  be  worn  on 
the  operator's  left  index  finger  to  prevent  the  patient  from  biting, 
is  both  unsafe  and  inconvenient. 

The  gauge  has  marks  showing  the  size  of  the  tube  for  the  given 
age  of  the  child.     The  operator  should  use  judgment  in  selecting 
the  tube  according  to  the  child's  size  and  develop- 
ment as  well  as  his  age. 

Braided  silk,  of  a  size  to  run  easily  through  the 
eyelet  in  the  head  of  the  tube  should  be  at  hand. 
About  eighteen  inches  of  thread  makes  one  loop. 
Introduction  of  the  Tube. — The  instruments 
should  be  laid  within  reach,  with  the  proper  tube 
selected  and  threaded  and  placed  upon  the  intro- 
ducer. It  is  well  to  warm  and  wet  the  instru- 
ments by  dipping  them  in  a  bowl  of  warm  water, 
before  using.  A  half  dozen  or  a  dozen  bits  of 
gauze  or  old  muslin  should  be  at  hand  to  be 
used  as  handkerchiefs  and  then  burned.  The 
patient  may  be  placed  in  either  one  of  two  posi- 
tions. The  first  position  is  sitting  upright  upon 
the  lap  of  the  nurse  with  his  back  toward  her 
left  shoulder.  His  arms  are  crossed  in  front 
of  his  abdomen.  The  nurse  clasps  his  right 
wrist  in  her  left  hand  and  his  left  wrist  in  her 
right.  And  she  is  told  not  to  lean  back,  not  to  let  the  child  slip 
down,  not  to  squeeze  his  chest  and  not  to  let  go  of  his  wrists  until 
further  orders.  I  prefer  this  method  to  swathing  the  child  in  a 
blanket  or  sheet,  which  is  almost  sure  to  become  bunched  up  under 
his  chin,  where  it  gets  in  the  way  of  the  handles  of  the  instru- 
ments ;  or  if  tight  it  will  compress  his  chest,  and  if  not  tight  allow 
him  to  get  a  hand  free.  An  assistant  (any  intelligent  person  will 
do,  but  a  physician  is  preferred)  stands  behind  the  nurse's  left 
shoulder  and  holds  the  child's  head  between  his  two  palms  He  is 
told  to  hold  the  head  straight  with  the  body  and  vertical,  and  keep 
the  gag  back  between  the  teeth  with  his  left  index,  and  keep  his 
thumb  off  the  trigger  of  the  gag.  These  points  are  explained  to 
nurse  and  assistant  before  any  attempt  is  made  to  use  the  gag,  as 
the  child  is  usually  docile  up  to  that  point.  A  child  who  has  no 
teeth  or  only  front  teeth  needs  no  gag.  The  operator's  finger 
is  kept  well  in  the  right  side  of  the  mouth.  All  being  in  readiness 
the  child  is  encouraged  and  reassured,  if  he  be  old  enough  to  under- 
stand ;  the  gag  is  placed  in  position,  the  introducer  with  the  tube  is 
picked  up  and  held  lightly  in  the  fingers,  the  loop  of  silk  caught 
with  the  little  finger.  The  directions  one  usually  reads  are  to  pass 
the  left  index  finger  back  into  the  throat  and  hook  up  the  epiglot- 


FiG.  177.  Mouth 


SURGERY    OF   AIR    PASSAGES  499 

tis,  then  pass  the  tube  in  along  the  finger  as  a  guide  and  introduce 
it  into  the  larynx.  A  better  way  is  to  merely  touch  the  base  of  the 
tongue  with  the  left  index  and  as  the  larynx  rises  and  opens  place 
the  end  of  the  tube  in  it  and  press  it  down.  In  either  maneuver 
the  tube  is  carried  into  the  mouth  with  the  handle  of  the  introducer 
held  low.  When  the  end  of  the  tube  comes  to  the  opening  of  the 
larynx  the  handle  is  elevated,  bringing  the  tube  to  the  vertical  posi- 
tion and  exactly  in  the  middle  line  of  the  larynx.  It  is  then  pressed 
downward  with  the  lightest  possible  pressure,  of  the  fingers  merely, 
is  detached  by  the  trigger  of  the  instrument,  and  is  held  in  the 
larynx  by  the  tip  of  the  left  index  while  the  obturator  is  removed. 
The  child  now  usually  has  a  paroxysm  of  coughing.  The  gag 
is  removed  and  the  discharges  wiped  away  by  the  operator,  being 
careful  not  to  pull  upon  the  thread  attached  to  the  tube.  Some- 
times, if  the  child  is  badly  asphyxiated  or  toxemic,  the  reflex  irrita- 
bility is  badly  obtunded  and  the  paroxysm  of  coughing  is  long 
delayed.  It  is  better  to  leave  the  thread  attached  to  the  tube  until 
several  coughing  spells  have  thoroughly  cleared  the  air  passage, 
which  may  take  five  to  fifteen  minutes  Usually  the  thread  can  be 
removed  without  reintroducing  the  gag,  if  the  lowermost  thread 
of  the  loop,  having  been  previously  marked,  is  gently  pulled  upon. 
But  if  it  does  not  come  with  the  slightest  traction  it  is  better  to 
reintroduce  the  gag  and  hold  the  tube  down  in  the  larynx  while 
withdrawing  the  thread.  The  nurse  may  now  release  the  child's 
wrists  and  place  him  in  bed. 

The  other  position  which  may  be  employed  is  with  the  child 
flat  upon  his  back.  Some  direct  to  have  him  rolled  in  a  blanket, 
but  I  prefer  to  have  his  wrists  held  by  a  person  who  also  controls 
his  thighs.  This  leaves  his  chest  free  and  nothing  in  the  way.  If 
the  operator  has  no  assistance  he  may  fasten  the  hands  with  a  towel 
about  both  wrists  and  passed  behind  the  patient's  thighs  and  pinned 
firmly  to  the  sleeves. 

The  advantages  of  the  dorsal  position  are  said  to  be  that  fewer 
assistants  are  required.  But  it  really  takes  just  the  same  number 
to  operate  conveniently.  There  is  some  advantage,  however,  in  that 
it  is  easier  for  the  heart  of  a  very  weak  patient.  He  need  not  be 
removed  from  the  horizontal  position  in  bed. 

The  time  required  to  introduce  the  tube  is  about  five  seconds. 
It  is  often  done  in  three  seconds.  It  should  never  take  longer  than 
ten.  This  longer  time  may  be  occasioned  by  a  twist  of  the  head  of 
ah  unruly  older  child  who  takes  the  assistant  unaware,  or  by  a  very 
small  mouth  or  low  arched  palate,  or  greatly  enlarged  tonsils,  or  a 
stiff  edematous  epiglottis.  No  attempt  to  introduce  the  tube  should 
be  prolonged  more  than  a  few  seconds.  If  the  attempt  fails  it  is 
better  to  desist,   let  the  child  have   a   few  breaths,   and  then   try 


500  SURGICAL   DISEASES    OF   CHILDREN 

again,  rather  than  to  make  a  prolonged  attempt.  A  beginner  is  very- 
apt  to  persist  until  the  patient  is  asphyxiated,  or  to  pass  the  tube  into 
the  esophagus,  or  to  push  the  membranes  before  the  tube  into  the 
trachea.  This  latter  accident  will  seldom  if  ever  occur  if  the  tube 
is  properly  placed  in  the  middle  line  and  down  in  the  larynx  before 
the  obturator  is  withdrawn.  To  remove  the  obturator  too  soon  and 
then  push  the  tube  home  with  the  finger  is  apt  to  gouge  the  false 
membrane  or  the  mucous  membrane  of  the  larynx. 

In  case  the  tube  is  placed  and  one  does  not  get  the  rush  of 
air  through  it,  but  the  patient  makes  ineilfectual  attempts  to  breathe, 
the  tube  must  be  withdrawn  at  once.  It  may  be  found  plugged  by 
a  bit  of  membrane  at  its  lower  end,  in  which  case  it  should  be 
cleared  and  introduced  again.  But  if  membrane  has  been  pushed 
down  ahead  of  the  tube  and  blocked  the  trachea  so  that  the  patient 
is  getting  no  air,  laryngo-tracheotomy  must  be  done  instantly.  If 
he  is  getting  a  little  air,  it  may  answer  to  intubate  with  one  of  the 
special  tubes  (Fig.  174),  with  large  caliber,  known  as  foreign  body 
tubes,  through  which  he  may  be  able  to  expel  a  mass  of  membranes. 

Occasionally  the  act  of  intubation  in  a  case  of  several  days 
standing  will  detach  loosened  membranes,  and  these,  in  a  paroxysm 
of  coughing,  will  be  expelled  together  with  the  tube.  This  occasions 
such  relief  of  the  dyspnea  that  no  tube  may  be  necessary.  If  the  tube 
be  not  directed  in  the  middle  line  of  the  larynx  its  end  may  be 
caught  in  a  ventricle  and  then  if  a  little  too  much  force  is  used  it 
may  be  thrust  through  the  larynx,  making  a  false  passage. 

After  Intubation. — There  is  just  one  essential  point  in  the 
management  of  the  intubation  case.  This  should  be  fully  explained 
and  demonstrated  to  the  nurse  or  parents,  namely,  the  child  cannot 
eat  solid  foods,  he  can  only  drink,  and  all  drinks  must  be  takeri 
in  the  recumbent  position  with  the  head  a  little  lower  than  the  body 
but  in  a  straight  line  with  the  spine.  A  position  lying  on  the  nurse's 
lap  with  the  head  hanging  over  her  knee,  as  one  sees  illustrated  in 
some  text  books,  is  not  correct.  The  drink  or  food  falls  into  the 
naso-pharynx,  instead  of  being  caught  by  the  muscles  of  deglutition. 
All  that  is  necessary  is  to  have  the  liquid  pass  the  open  end  of  the 
tube  and  enter  the  pharynx.  During  the  first  day  or  two  swallowing 
is  not  well  performed.  If  the  child  drinks  while  in  the  upright  posi- 
tion, or  in  any  position  excepting  with  the  top  of  the  tube  pointed 
a  little  downward,  the  liquid  may  enter  the  trachea  through  the  open 
tube  and  excite  paroxysmal  coughing.  This  position  during  feeding, 
suggested  by  Casselberry  of  Chicago,  is  really  the  only  point  of  any 
value  that  has  been  added  to  O'Dwyer's  treatment.  Children  can 
take  milk,  egg-nog,  strained  gruels,  ice  cream,  and  such  liquids  or 
semisolids.  Nursing  infants  may  be  left  at  the  breast.  If  a  child 
will  not  swallow  nutriment  he  must  be  nourished  by  enemata.  Good 
nourishment  is  very  important. 


SURGERY    OF   AIR    PASSAGES  501 

It  goes  without  saying  that  intubation  in  no  sense  takes  the 
place  of  treatment  by  antitoxin  or  of  any  medicinal  treatment  that 
may  be  indicated.  It  is  merely  a  mechanical  means  of  overcoming 
the  laryngeal  obstruction  until  such  time  as  the  disease  subsides 
or  has  been  conquered  by  nature,  by  antitoxin  or  medication. 

After  intubation  the  child  generally  falls  asleep  and  often 
rests  for  several  hours.  The  tube  may  not  require  the  slightest 
attention  for  a  day  or  two  or  three  days.  In  rare  cases  the  tube 
may  become  obstructed  by  loose  membrane  below  it,  in  which  case 
if  not  fitted  too  tightly,  tube  and  membrane  will  be  expelled  by 
cough.  Cases  have  occurred  in  which  too  large  a  tube  was  used  or 
the  tube  had  become  impacted,  or  the  obstruction  had  taken  place 
when  there  was  so  little  air  in  the  lungs  that  coughing  was  impossible 
or  ineffectual  and  the  patient  succumbed.  But  this  is  very  unusual. 
Cases  of  spontaneous  descent  of  the  tube  in  the  larynx  have  been 
reported,  causing  great  difficulty  in  extubation  or  even  requiring 
tracheotomy.  This  seems  to  me  impossible  unless  a  tube  far  too 
small  for  the  child  be  used. 

The  tube  may  become  gradually  occluded  with  mucus,  and 
especially  with  food  particles  and  mucus  together,  if  the  feeding 
is  badly  managed.  This  may  require  extubation  for  clearing  the 
tube ;  or,  all  being  in  readiness  for  extubation,  a  drink  of  whisky  and 
water  may  excite  cough  that  will  clear  the  tube. 

The  child  may  expel  the  tube  by  coughing.  If  this  occurs  soon 
after  intubation  it  is  probable  the  tube  is  too  small.  If  the  tube  is 
unobstructed  this  explanation  is  certainly  the  right  one.  In  some 
cases  recession  of  swelling  and  loosening  of  membranes  occurring 
some  hours  or  days  after  intubation  will  cause  the  tube  to  be 
coughed  out.  In  this  case  the  surgeon  should  be  immediately  in- 
formed what  has  occurred.  Yet  it  may  be  that  the  trouble  is  over 
and  reintubation  is  not  required.  In  some  cases  of  auto-extubation 
the  larynx  seems  perfectly  clear  at  first,  but  in  an  hour  or  a  few 
hours  stenosis  returns. 

Extubation. — The  average  time  that  a  tube  is  worn  in  the 
larynx  is  five  days.  Many  cases  are  extubated  in  two  or  three  days. 
There  is  no  absolute  rule.  One  must  be  guided  by  the  conditions 
in  the  individual  case.  Ordinarily,  if  there  is  fever  or  the  child 
is  very  weak  and  yet  taking  food  well,  it  is  better  to  wait.  It  can 
seldom  be  useful  to  attempt  extubation  before  the  third  or  fourth 
day,  and  one  has  no  misgivings  about  leaving  the  tube  in  place 
a  week  if  all  is  going  on  well.  With  the  advent  of  antitoxin  there 
was  a  tendency  to  shorten  the  period  extremely,  some  operators 
priding  themselves  on  the  short  time  the  tube  was  worn.  Undoubt- 
edly antitoxin  does  shorten  by  two  days  or  more  the  time  it  is 
necessary  to  wear  the  tube.  But  that  fashion  of  extreme  haste 
passed  by.     The  use  of  the  hard  rubber  instead  of  metallic  tubes 


502  SURGICAL   DISEASES    OF   CHILDREN 

had  an  influence  to  lengthen  the  time ;  for  the  gutta-percha  tube 
does  not  become  roughened  by  incrustation  Hke  the  metalhc  tube, 
and  causes  no  irritation  by  remaining  a  sufficient  time  to  avoid 
the  necessity  of  reintubating.  Occasionally  one  is  persuaded  to 
extubate  as  soon  as  possible  by  the  child's  refusal  to  take  the  neces- 
sary amount  of  food,  and  failing  to  retain  nutrient  enemata. 

Extubation  may  be  performed  with  the  patient  either  sitting 
or  lying,  in  the  same  positions  as  for  intubation ;  and  the  positions 
and  duties  of  the  assistants  are  the  same. 

In  nearly  all  cases,  when  preparing  for  extubation,  the  operator 
should  select  a  tube  of  size  similar  to  the  one  he  intends  to  remove 
and  have  it  threaded  with  silk  and  ready  upon  the  introducer ;  for  it 
not  infrequently  happens  that  upon  removing  a  tube  from  the  larynx, 
dyspnea  will  return  so  severely  and  so  suddenly  that  unless  re- 
intubation  be  instantly  performed  the  child  will  suffocate.  Extuba- 
tion is  somewhat  more  difficult  of  performance  than  intubation,  espe- 
cially in  a  very  young  child  with  small  mouth  and  low  palate.  The 
gag  is  used.  The  left  index  finger  finds  the  head  of  the  tube  and 
keeps  the  epiglottis  raised.  The  closed  beak  of  the  extractor  is  in- 
troduced into  the  opening  at  the  top  of  the  tube  and  then  opened 
so  as  to  seize  the  tube,  which  is  then  gently  lifted  out  with  a  reversal 
of  the  motion  used  on  introducing  it.  That  is,  it  is  lifted  straight  up 
until  it  clears  the  larynx,  then  the  handle  of  the  instrument  is  de- 
pressed as  it  is  withdrawn  from  the  mouth.  The  error  most  likely 
to  be  made  in  efforts  at  extubation  is  to  pass  the  beak  of  the  extractor 
between  the  tube  and  the  rim  of  the  glottis  and  then  by  spreading 
the  blade  lacerating  the  tissues.  Before  using  the  extractor  the 
width  to  which  the  beak  can  be  opened  should  be  regulated  by  the 
set  screw,  being  only  sufficient  for  the  size  of  the  tube.  Extubation 
may  be  performed  by  digital  expression  without  the  use  of  instru- 
ments. There  are  two  principal  methods,  Renault's  and  Marfan's. 
(See  Figs.  178a,  179a,  i8oa,  iSia.^)  Renault's  method  is  a  modi- 
fication of  that  originated  by  Bayeux  and  is  executed  as  follows: 
The  child  sits  on  the  edge  of  the  bed  or  on  the  lap  of  the  nurse, 
who  confines  its  hands  at  its  sides.  The  operator,  facing  the  child, 
places  the  pulp  of  his  right  thumb  in  front  of  the  child's  throat 
opposite  the  lower  end  of  the  tube,  while  his  hand  encircles  the 
neck,  his  fingers  at  the  nape.  His  left  hand  is  placed  upon  the 
child's  head,  the  fingers  upon  the  occiput.  The  right  thumb  now 
gently  pushes  the  tube  upward  until  its  lower  end  is  level  with  the 
cricoid  cartilage.  The  body  of  the  child,  by  flexion  on  the  thighs, 
is  now  swung  rapidly  forward,  thus  throwing  the  tube  into  the 
mouth,  whence  it  is  extracted  by  the  fingers. 

In  Marfan's  method  the  child  lies  prone  with  its  head  and  neck 

1  J.  R.  Clemens,  Archives  of  Pediatrics,  Feb.,  1908. 


SURGERY   OF  AIR   PASSAGES 


503 


extending  beyond  the  edge  of  a  table  or  bed.  Its  forehead  is  sup- 
ported on  the  left  hand  of  the  operator,  who  places  the  pulp  of  his 
right  index  finger  upon  the  trachea  below  the  tube  and  his  thumb 
on  the  nape  of  the  neck.  The  child's  head  is  now  gently  extended 
with  the  left  hand,  and  the  right  index  feels  the  lower  end  of  the 
tube.  The  head  is  now  flexed,  while  at  the  same  time  the  tube  is 
pressed  upward  into  the  mouth.    Of  the  two  methods,  Marfan's  is 


Figs.    178a   and   179a.     Renault's   method  of  Extubation. 


Figs.    i8oa  and    iSia.     Marfan's    method  of  Extubation. 


the  better,  but  for  my  own  use  I  still  prefer  the  instrumental  ex- 
traction. 

After  removing  the  tube,  the  operator  should  wait  twenty  or 
thirty  minutes  to  see  whether  dyspnea  returns.  If  it  does  not  in  that 
length  of  time  it  probably  will  not  for  several  hours,  and  he  should 
be  on  call  during  that  time.  If  the  patient  gets  through  the  first 
succeeding  night  without  dyspnea  it  will  probably  not  return.  It  is 
well  to  deprive  the  patient  of  food  for  two  or  three  hours  before 


504  SURGICAL   DISEASES    OF   CHILDREN 

extubation  and  to  use  a  preparatory  dose  of  codeine,  morphine, 
bromide  or  chloral,  or  similar  cough  sedative.  After  extubation 
food  should  be  given  with  the  same  precautions  as  while  wearing 
the  tube,  for  several  hours,  as  the  muscles  controlling  the  move- 
ments of  the  epiglottis  and  the  act  of  deglutition  are  not  well  con- 
trolled. Aphonia,  or  at  least  a  degree  of  hoarseness,  may  be  ex- 
pected to  remain  for  a  few  days  or  a  week  or  in  some  instances  for 
several  weeks.     I  have  never  had  it  to  remain  permanently. 

Retained  Tube  ;  Prolonged  Intubation. — Many  cases  require 
but  one  intubation  and  one  extubation  a  few  days  later.  It  is  not 
uncommon  to  be  obliged  to  extubate  and  reintubate  two  or  three 
times  at  intervals  of  a  few  days  before  the  tube  can  be  permanently 
dispensed  with.  But  cases  in  which  serious  difficulty  is  experienced 
in  getting  along  without  the  tube  are  not  nearly  so  common  in  intuba- 
tion as  in  tracheotomy  Almost  always  the  tube  can  be  finally  left 
out  after  five  or  six  extubations  in  the  course  of  a  few  weeks.  Yet 
cases  are  reported  in  which  it  seems  impossible  for  the  child  to 
breathe  without  the  tube.  He  appears  perfectly  well  with  the  tube, 
yet  if  it  is  removed  the  dyspnea  returns  either  immediately  or  a  few 
hours  later.  Some  of  these  cases  also  cough  out  the  tube  readily 
several  times  a  day  or  night,  and  are  very  distressing  to  the  patient 
himself  and  his  friends  and  to  the  surgeon.  A  special  tube  with  a 
larger  central  portion,  or  even  a  larger  ordinary  tube  will  be  better 
retained.  (Fig.  173,  iii.)  Patients  have  been  known  to  wear  tubes 
for  years,  notwithstanding  frequent  attempts  to  do  without.  Opin- 
ions are  not  unanimous  as  to  the  real  cause  of  this  condition.  Some 
of  these  cases  when  explored  by  laryngotomy  have  presented  noth- 
ing apparently  accounting  for  the  symptoms.  Exuberant  granula- 
tions, which  are  so  common  after  tracheotomy,  seldom  give  trouble 
after  intubation.  Special  tubes  are  made  for  such  conditions.  (Fig. 
173,  i,  ii.)  Rogers  considers  this  troublesome  condition  a  chronic 
inflammation  of  the  mucous  and  submucous  tissues  resulting  from 
the  original  diphtheritic  laryngitis.  He  treated  it  successfully  by 
very  gradual  dilatation  with  larger  and  larger  tubes,  until,  after  treat- 
ment extending  over  months,  when  the  patient  had  worn  a  tube  very 
large  for  his  size,  he  was  able  to  do  without  any.^ 

Intubation  for  Chronic  Stenosis  of  the  Larynx. — Intuba- 
tion has  several  very  useful  applications  in  addition  to  that  in  acute 
stenosis  in  diphtheria.  It  is  very  useful  in  cases  of  retained  tracheot- 
omy tube.  In  papilloma  of  the  larynx  it  has  been  used  with  success. 
(See  Section  on  Papilloma  of  the  Larynx.)  It  is  useful  in  stenosis 
or  partial  stenosis,  either  inflammatory  or  cicatricial,  resulting  from 
trauma,  burns,  scalds,  caustics,  simple  inflammation,  tuberculosis, 
syphilis,  malignant  growths,  ankylosis  of  the  arytenoid  articulations, 
hysterical  spasm  of  the  larynx  and  other  conditions. 
1  Annals  of  Surgery,   May,   1900. 


SURGERY    OF   AIR   PASSAGES  505 

Laryngotomv. — Laryngotomy,  or  as  it  is  sometimes  called, 
thyrotomy,  has  its  most  frequent  indication  in  the  presence  of 
tumors  of  the  larynx,  which  could  not  be  removed  by  endolaryn- 
geal  methods.  It  is  therefore  described  as  it  would  be  performed 
for  the  removal  of  a  tumor.  As  Holmes  long  ago  pointed  out,  and 
has  since  been  reiterated  by  other  surgeons,  laryngotomy  for  the 
removal  of  a  growth  needs  a  preliminary  tracheotomy.  For  this 
purpose  an  infra-isthmian  tracheotomy  is  better  than  one  above  the 
isthmus  which  is  too  near  the  laryngeal  wound  for  convenience. 
However,  a  supra-isthmian  tracheotomy  may  be  made.  When  it  is 
possible,  the  preliminary  tracheotomy  should  precede  the  laryngot- 
omy by  a  few  days.  Thus  an  air  supply  is  provided  for  both  during 
and  after  the  operation ;  and  also  the  blood  can  be  prevented  from 
entering  the  bronchi  by  the  use  of  Trendelenburg's  tampon-canula, 
or  in  its  stead  by  blocking  the  trachea  above  an  ordinary  tracheotomy 
tube  with  soft  little  sponges  each  securely  tied  to  a  string.  To  open 
the  larynx,  general  anesthesia  is  required.  For  any  variety  of  ex- 
ternal aeroporotomy  the  following  instruments  and  articles  should 
be  at  hand :  Scalpel,  bistoury,  two  pairs  dissecting  forceps,  a  grooved 
director,  several  pairs  of  hemostats,  scissors,  sharp  hook,  a  dilator, 
a  couple  of  needles  and  a  few  sutures  of  silk,  a  tracheal  dilator,  a 
pair  of  small  retractors,  hard  rubber  or  silver  tracheotomy  tubes  of 
several  sizes  and  different  curves,  with  tapes  for  the  same;  small 
sponges  with  strings  attached,  a  few  feathers,  gauze  sponges,  sterile 
gauze  and  antiseptics,  a  solution  of  cocaine.  If  a  tumor  is  to  be 
removed,  a  galvano-cautery  apparatus,  or  a  Paquelin,  or  chromic 
acid  should  be  in  readiness  to  cauterize  the  stump. 

The  patient  lies  upon  the  back  with  head  exactly  straight  and 
well  extended  over  a  firm  roll  (of  the  size  of  his  arm)  which  is  placed 
beneath  his  neck.  The  incision  is  carried  downward  in  the  median 
line  from  the  hyoid  bone  to  the  upper  part  of  the  trachea.  The 
hyoid  and  crico-thyroid  arteries  and  other  vessels  will  be  divided  and 
should  be  tied.  The  sterno-hyoid  muscles  are  drawn  apart  and  the 
thyroid  cartilage  being  well  exposed  its  alae  are  transfixed  trans- 
versely with  a  silk  suture.  (Pitts.)  The  cartilage  is  divided  pre- 
cisely in  the  middle  line,  the  suture  passing  across  within  the  larynx 
being  drawn  out  through  the  opening  and  cut  in  the  middle,  making 
a  retractor  for  each  ala.  The  interior  of  the  larynx  is  thus  exposed 
to  view  and  a  solution  of  cocaine  is  applied  to  inhibit  reflex  con- 
tractions. The  growths  are  then  removed  with  scissors  and  their 
stumps  touched  with  the  finest  point  of  a  Paquelin  cautery.  Some 
operators  use  chromic  acid  as  a  caustic  and  some  remove  the  growths 
with  the  galvano  cautery  or  sear  the  stumps  with  the  galvanic  point. 
The  retractors  are  then  removed  and  the  al?e  of  the  thyroid  care- 
fully sutured  together;  likewise  the  skin  wound.  The  tracheotomy 
tube  is  still  used  for  a  few  days  after  the  operation  on  the  larynx. 


So6    .  SURGICAL  DISEASES    OF   CHILDREN 

Laryngo-tracheotomy  or  Crico-tracheotomy  is  the  form  of 
external  aeroporotomy  most  often  performed  on  children.  Tracheot- 
omy in  one  form  or  another  is  by  no  means  a  modern  operation,  hav- 
ing been  known  to  the  ancients  under  the  name  of  bronchotomy, 
but  was  revived  by  Bretoneau  in  1825  and  by  Trousseau  in  1833. 
From  that  time  until  the  introduction  of  intubation  by  O'Dwyer  in 
1885  it  was  the  operation  most  commonly  used  for  laryngeal  diph- 
theria. Laryngo-tracheotomy,  as  well  as  tracheotomy,  also  has  an 
application  as  a  preliminary  step  in  bloody  operations  upon  mouth, 
throat  or  larynx,  in  cases  of  foreign  body  in  the  air  passage,  and  in 
obstructions  of  the  air  supply  from  edema,  inflammatory  stenosis  or 
the  like.  The  advantages  and  disadvantages  of  intubation  and 
laryngo-tracheotomy  are  pointed  out  in  the  section  on  intubation. 
This  supra-isthmian  operation  has  the  advantage  over  that  which 
enters  the  trachea  below  the  isthmus,  in  that  the  trachea  above  lies 
nearer  to  the  surface  and  the  space  in  front  of  it  is  nci  so  vascular 
as  that  at  the  lower  part  of  the  neck. 

The  anatomical  conditions  are  very  different  in  the  child  as 
compared  with  the  average  adult.  The  neck  is  short,  for  the  reason 
that  the  sternum  is  higher — nearly  the  width  of  one  vertebra  higher 
— than  in  the  adult.  Consequently  there  is  little  room  for  work,  and 
the  trachea  lies  at  comparatively  greater  depth.  When  one  con- 
siders also  the  small  size  of  the  larynx,  the  thickness  of  the  sub- 
cutaneous fat,  the  turgid  condition  of  the  veins  usually  present  in 
the  half-suffocated  patients  that  usually  require  aeroporotomy,  and 
the  constant  motion  of  the  parts  in  the  efforts  at  breathing,  one 
begins  to  realize  the  difficulties  of  an  operation  that,  practiced  on 
the  cadaver  of  an  adult,  appears  too  simple  to  require  any  instruc- 
tion. When  the  operation  must  be  done  on  short  notice,  in  the  night, 
with  poor  light,  and  no  facilities,  and  the  necessary  danger  of 
chloroform  with  an  asphyxiated  and  almost  exhausted  patient,  and 
of  blood  running  into  the  trachea,  and  the  distracted  parents  and 
friends  of  the  child  in  hysterics,  it  is  no  easy  or  pleasant  undertaking. 

The  instruments  required  are  mentioned  in  the  section  on  laryn- 
gotomy.  All  necessary  preparation  should  be  made  before  the 
patient  is  moved.  If  possible,  one  should  have  a  trusty  assistant 
besides  the  anesthetist.  General  anesthesia  is  necessary  unless  the 
patient  is  unconscious  from  asphyxia — too  comatose  to  be  roused  by 
pain.  All  the  light  available  should  be  placed  to  the  best  advantage. 
The  patient's  wrists  should  be  securely  rolled  and  pinned  fast  in 
a  towel  which  passes  behind  him,  as  he  lies  on  the  table  flat  on  his 
back.  He  should  be  held  in  position  by  someone  who  will  not 
be  frightened  or  turn  faint.  A  cushion  or  small  pillow  is  placed  un- 
der his  shoulders  or  a  firm  roll  of  the  size  of  his  arm  put  under 
his  neck,  so  that  the  head  is  well  extended.    As  Owen  says,  "  The 


SURGERY   OF   AIR   PASSAGES  507 

trachea  is  to  be  pulled  up  out  of  the  chest."  The  head  should  be 
held  exactly  straight  with  the  body,  otherwise  the  operator  is  very 
apt  to  miss  the  trachea.  The  operator  stands  at  the  patient's  right 
side.  The  landmarks  are  the  thyroid  cartilage  and  the  episternal 
notch.  The  thyroid  cartilage  is  located  by  the  left  index,  and  an 
incision  is  carried  down  the  front  of  the  neck,  precisely  in  the 
median  line,  a  distance  of  one  and  a  half  or  two  inches.  There  is 
an  advantage  in  having  a  good  long  skin  incision.  It  gives  room  to 
work  in  the  depth,  and  there  is  less  danger  of  emphysema  of  cellular 
tissues  from  air  expelled  from  the  trachea.  One  should  be  careful 
not  to  get  his  incision  too  low,  or  he  will  find  himself  upon  or  below 
the  isthmus.  The  first  incision  goes  through  skin  and  the  usually 
abundant  subcutaneous  fat.  The  wound  is  now  retracted  and  the 
dissection  is  continued  until  the  straight  ribbon  muscles  in  front  of 
the  neck,  the  sterno-hyoids,  and  beneath  them  the  sterno-thyroids, 
are  found  with  the  fascial  septum  connecting  their  margins.  A 
blunt  dissector  (handle  of  scalpel  or  a  grooved  director  or  a  dis- 
secting forceps,  closed)  will  separate  the  muscles  in  the  middle 
line.  If  turgid  veins  are  seen,  the  venae  colli  media,  they  should 
be  pushed  aside,  or  if  they  must  be  divided  they  should  be  seized 
with  hemostats  and  cut  between.  We  now  come  to  the  trachea 
covered  with  a  fascia  or  with  the  isthmus  of  the  thyroid.  Some 
operators  advise  to  cut  or  tear  right  through  the  isthmus,  others 
will  say  to  ligate  it  at  each  side  and  divide  between.  The  former 
produces  hemorrhage,  of  which  there  is  apt  to  be  a  plenty,  and  the 
latter  takes  time.  Neither  procedure  is  necessary.  A  better  plan  is 
Bose's.  At  the  upper  margin  of  the  isthmus  the  fascia  which  binds 
it  to  the  cricoid  cartilage  and  the  trachea  beneath  is  divided,  and  the 
isthmus  is  forced  toward  the  sternum  by  a  blunt  dissector  or  a  nar- 
row retractor,  until  several  tracheal  rings  are  exposed.  A  strong 
hook  is  inserted  into  the  cricoid  cartilage,  which  is  pulled  toward  the 
chin.  There  will  be  some  oozing  of  blood,  but  the  trachea  should  be 
seen  or  plainly  felt  with  the  tip  of  the  left  index  finger.  A  sharp- 
pointed  knife,  with  its  back  against  the  retractor  which  protects 
the  isthmus,  pricks  through  the  anterior  wall  of  the  trachea  and 
cuts  upward,  severing  two  or  three  upper  rings  and  then  the  cricoid 
cartilage,  making  an  incision  about  three-fourths  of  an  inch  (19 
mm.)  in  length.  Immediately  there  is  a  rush  of  air  out  and  in 
through  the  incision,  spattering  bloody  mucus  and  sometimes  mem- 
brane into  the  operator's  face  and  eyes  unless  he  is  wary.  A  dilator 
is  slipped  into  the  trachea,  and  any  fragments  of  membrane  within 
reach  are  picked  out.  If  the  trachea  is  filled  with  tough  mucus 
a  feather  passed  down  clears  it. 

Unfortunately,  however,   an   inexperienced   operator  ma}^  find 
that  his  bistoury  had  not  entered  the  trachea;  he  may  have  passed 


5o8  SURGICAL   DISEASES    OF   CHILDREN 

it  down  at  one  side ;  and  this  is  especially  apt  to  be  the  case  if  the 
head  is  not  held  squarely  and  straight,  and  well  extended,  or  he 
forgets  to  keep  his  incision  precisely  in  the  middle  line.  Or  his  knife 
may  not  have  cut  through  the  mucous  lining  of  the  trachea.  This 
is  very  disconcerting.  But  he  must  keep  his  head,  and  take  his 
bearings,  sponge  out  the  wound,  see  or  feel  the  tracheal  rings  and, 
if  he  had  not  done  so,  incise  them. 

It  is  well  to  pass  a  silk  suture  through  each  lip  of  the  tracheal 
wound  and  by  tying  these  behind  the  neck  the  margins  of  the  slit 
are  retracted.  A  tracheotomy  tube  with  tapes  attached  is  passed 
between  the  blades  of  the  dilator  into  its  place,  and  tied  at  the  back 
of  the  neck.  The  tube  should  not  completely  fill  the  tracheal  wound ; 
but  it  should  be  of  the  right  curve  so  that  neither  edge  of  its  lower 
end  impinges  on  the  tracheal  wall.  A  child's  trachea  is  some- 
thing near  the  size  of  its  index  finger ;  but  it  is  not  difficult  to  tell  the 
right  sized  tube  if  one  is  careful  not  to  have  it  too  large.  Be  sure 
the  inner  tube  slips  in  and  out  of  the  outer  easily  and  locks  in 
readily,  before  inserting  into  the  trachea ;  and  be  careful  not  to  push 
false  membrane  down  ahead  of  it ;  nor  to  push  the  tube  between 
false  membrane  and  the  tracheal  wall.  With  the  first  full  breath 
the  turgidity  disappears  from  the  veins  about  the  throat.  Sometimes, 
after  a  deep  breath,  the  patient  ceases  to  breathe — alarming  the 
uninitiated  operator.  But  this  is  only  apnea,  induced  by  the  unusual 
supply  of  oxygen,  and  after  a  pause  breathing  is  resumed.  With  a 
few  breaths  cyanosis  disappears.  If  the  patient  does  not  cough 
vigorously,  or  the  trachea  seems  blocked,  a  feather  inserted  and 
twirled  around  will  excite  cough  and  a  mass  of  mucus  or  mem- 
brane forced  up  into  the  wound  should  be  quickly  caught  with 
gauze  sponge  or  forceps  and  removed.  Or  the  obstruction  may  be 
forced  out  by  sudden  compression  of  the  chest,  and  then  artificial 
respiration  kept  up  a  half  hour  if  necessary  until  the  natural  breath- 
ing is  established.  The  front  of  the  throat  is  covered  with  moist 
gauze,  to  filter  and  warm  the  air  before  its  ;entrance  into  the  bron- 
chise  and  lungs. 

Competent  nursing  is  requisite.  The  nurse  should  be  able  to 
remove  the  inner  tube  and  clean  and  replace  it,  and  renew  the 
gauze  dressing ;  and  should  have  sufficient  skill  and  coolness  to  do 
this  instantly  if  the  tube  should  suddenly  become  blocked  and  the 
child  be  suffocating.  She  should  not  be  allowed  to  brush  the  trachea 
with  feather  or  camel's  hair  brush  too  often,  as  irritation  may  occur. 
The  patient  must  not  be  left  alone  for  a  moment  either  day  or  night, 
A  dilator  should  always  be  at  hand,  for  use  in  case  a  tube  became 
blocked  or  displaced,  or  required  changing.  The  air  in  the  room 
must  be  kept  at  a  temperature  of  70  degrees  F.  and  moistened  by 
steam.    The  tent  over  the  bed,  as  often  recommended,  may  be  useful 


SURGERY    OF   AIR    PASSAGES  509 

if  the  proper  temperature  or  moisture  cannot  otherwise  be  secured, 
or  the  room  is  draughty.  But  the  air  under  a  small  tent  soon  becomes 
badly  rebreathed. 

The  child  must  be  supported  with  stimulants  and  food,  whisky 
and  brandy  or  peptonoids,  wine,  whey,  egg  water,  gruels.  If  these 
cannot  be  readily  swallowed,  as  may  happen  from  diphtheritic 
paralysis  or  from  fear  of  pain  in  the  wound,  he  must  be  fed  by  gav- 
age  or  by  the  rectum.  (See  Section  on  Gavage.)  Great  care  should 
be  exercised  to  avoid  vomiting.  Vomiting  is  a  very  distressing  and 
dangerous  symptom  in  patients  wearing  either  tracheotomy  or  in- 
tubation tubes. 

Among  the  drugs,  quinia  and  strychnia  are  the  best  at  this 
stage.  Mercury  by  mouth  inunction  or  sublimation  may  be  used  if 
necessary.  If  antitoxin  has  been  used,  mercury  is  not  administered 
so  heroically  as  without  the  serum. 

Infra-isthmian  Tracheotomy  (the  "  Inferior  Operation," 
OR  Infra-glandular  Tracheotomy). — Between  the  isthmus  of  the 
thyroid  and  the  top  of  the  sternum  the  vertical  muscles  are  more 
widely  separated  than  above,  and  it  would  appear  easier  to  reach 
the  trachea  in  this  situation.  But  it  is  more  deeply  embedded  here 
than  near  the  larynx,  and,  besides  the  skin  and  the  fascial  layers 
and  a  good  deal  of  adipose  tissue,  which  give  the  operator  no  anxiety, 
there  is  a  network  of  veins  that  is  difficult  to  pass  without  trouble- 
some hemorrhage,  especially  when  they  are  swollen  with  blood 
in  a  patient  struggling  for  breath  with  laryngeal  stenosis.  In 
children  an  enlarged  thymus  gland  may  be  crowded  up  to  the  lower 
margin  of  the  thyroid.  Moreover,  there  is  more  likely  to  be  abscess 
from  the  wound  extending  into  the  mediastinum,  or  emphysema  of 
the  connective  tissues,  in  the  lower  operation.  Therefore,  this 
operation  is  not  usually  chosen  in  diphtheria  or  cellulitis,  but  it 
may  be  preferred  as  a  step  preliminary  to  extensive  operation  upon 
larynx  or  throat,  or  in  case  of  foreign  body  lodged  in  a  bronchus. 
The  preparation,  the  instruments  and  position  of  the  patient  are  the 
same  as  described  for  the  other  varieties  of  external  aeroporotomy. 
The  incision  is  precisely  in  the  middle  line,  an  inch  and  a  half  or 
two  inches  (four  or  five  cm.)  in  length,  ending  below  at  the  epi- 
sternal  notch.  After  the  skin  and  adipose  are  severed  and  retracted 
the  blunt  dissector  is  employed,  and  when  connective  tissue  must 
be  cut  it  is  lifted  with  tissue  forceps.  Veins  are  held  aside  with 
dissector  or  blunt  retractors.  The  arteria  thyroideaima,  extending 
upward  along  the  front  of  the  trachea,  from  the  innominate  artery 
to  the  thyroid  gland,  and  the  large  inferior  thyroid  vein  coming 
down,  may  be  encountered,  and  should  be  avoided  or  secured 
before  division.  When  the  trachea  is  exposed,  a  flat  retractor  holds 
the  isthmus  of  the  thyroid  toward  the  chin,  while  a  knife  pricked 


Sio  SURGICAL   DISEASES    OF   CHILDREN 

through  the  trachea  below  cuts  toward  it.  The  dilator  is  intrcxiuced, 
the  trachea  cleared,  foreign  body  removed  by  the  patient's  efforts 
at  coughing,  or  by  suspending  him  by  the  heels,  or  by  long  curved 
forceps,  or  a  soft  wire  hook.  Or  the  bronchoscope  or  a  tracheot- 
omy tube  introduced,  according  to  the  purpose  of  the  operation. 

Permanent  Removal  of  the  Tube  is  a  matter  often  requiring 
considerable  management.  As  soon  as  the  laryngeal  disease  has  sub- 
sided and  the  child  is  in  fit  condition  for  slight  disturbance,  he 
should  be  practiced  at  breathing  through  the  larynx  by  temporarily 
withdrawing  the  inner  tube  and  placing  a  finger-tip  over  the  outside 
opening  or  blocking  it  with  a  plug.  This  practice  should  not  be 
too  long  delayed — not  more  than  a  few  days,  or  the  larynx  becomes 
so  unaccustomed  to  the  rush  of  air  that  it  does  not  want  to  tolerate 
it,  closing  spasmodically  and  producing  dyspnea.  When  the  child 
has  learned  to  breathe  quietly  with  the  tube  blocked,  the  latter 
should  be  removed  for  a  time,  while  the  dilator  is  held  ready  to  open 
the  trachea  and  reintroduce  the  tube  if  trouble  arises.  If  all  goes 
well  the  tube  may  be  left  out  longer  and  longer  at  a  time.  But 
someone  should  be  at  hand  who  could  introduce  it ;  for  occasion- 
ally, either  gradually  or  suddenly,  dyspnea  may  supervene  quite 
unexpectedly.  Dyspnea  is  more  apt  to  come  on  at  night  or  if  the 
child  becomes  frightened  or  cries  or  swallows  imperfectly.  It 
may  be  weeks  or  months  before  the  tube  can  be  permanently  laid 
aside.  Intubation  may  have  to  be  resorted  to,  as  an  aid  in  dispens- 
ing with  the  tracheotomy  tube.  One  should  not  take  it  for  granted 
that  any  difficulty  of  breathing  which  may  be  present  is  certainly 
spasmodic,  or  due  to  fright,  or  even  to  diphtheritic  paralysis  of 
laryngeal  muscles.  There  may  be  actual  obstruction  by  exuberant 
granulations,  or  by  adhesion  of  the  vocal  cords.  One  could  relate 
some  interesting  experiences  along  this  line  if  space  permitted. 

THYMIC    ASTHMA;    THYMIC    TRACHEOSTENOSIS; 
THYMECTOMY 

Thymic  asthma (37)  has  been  alluded  to  in  the  section  on  Lymph- 
atism.  At  present  there  is  no  clear  understanding  of  the  pathology 
of  the  condition  in  which  dyspneic  attacks  or  sudden  death  take 
place  and  nothing  pathological  but  a  hyperplastic  thymus  is  found 
at  autopsy.  Jackson  has  demonstrated  by  tracheoscopy,  in  at  least 
one  case  in  the  living  patient,  the  purely  mechanical  nature  of 
thymic  asthma,  proving  what  Friedleben,  von  Kundrat,  d'Escherich 
and  Paltauf  have  denied,  that  a  hypertrophic  thymus  can  compress 
the  trachea  sufficiently  to  obliterate  its  lumen,  producing  what  he 
suggests  calling  tracheo-stenosis.  It  is  probable  that  progress  in  the 
understanding  and  treatment  of  these  cases  will  in  the  near  future 
lead  more  frequently  to  operation.     Some  seven  or  more  thymect- 


SURGERY    OF    AIR    PASSAGES  S" 

omies  for  this  affection  have  been  reported  and  the  results  fully 
justify  the  operation.  Jackson  gives  excellent  points  on  the  sub- 
ject.^ 

A  radiograph  aids  in  the  diagnosis.  The  dyspnea  is  expiratory, 
the  intrathoracic  pressure  being  then  at  its  greatest,  and  is  worse  in 
the  erect  position.  A  positive  diagnosis  of  tracheo-stenosis  can  be 
made  with  the  tracheoscope,  but  upper  tracheoscopy  is  probably  not 
safe  in  these  cases. 

Tracheotomy  as  high  as  possible  should  be  done,  under  in- 
filtration anesthesia,  the  stenosis  demonstrated  with  the  broncho- 
scope, and  then  a  tracheal  canula,  long  enough  to  reach  below 
the  obstruction,  should  be  inserted.  The  long  tracheal  canula  is  of 
great  importance,  not  only  relieving  the  dyspnea  for  the  time  being, 
but  preventing  undue  pressure  on  the  trachea  and  consequent 
asphyxia  during  the  removal  of  the  thymus  which  is  to  follow. 

The  thymectomy  may  now  be  postponed  for  some  hours,  days, 
or  weeks,  if  necessary,  for  the  child  to  recover  condition.  In  thy- 
mectomv  a  transverse  incision  is  made  at  or  just  below  the  upper 
border  of  the  sternum,  the  flap  retracted  upward  and  the  sternal 
attachments  of  both  sterno-hyoids  divided.  The  dissection  is  carried 
down  to  the  thymus  gland  which  will  probably  bulge  into  the  wound. 
The  little  finger  is  passed  down  into  the  wound,  breaking  up  the 
attachments  of  the  thymus,  taking  care  not  to  wound  the  pleurae  or 
the  pericardium.  The  gland  is  gradually  loosened  and  drawn  out, 
any  strong  attachments  being  ligated  and  cut,  and  nearly  the 
entire  gland  may  be  divided  and  removed  after  ligation.  The  finger 
should  not  be  kept  long  in  the  mediastinum,  for,  although  the  long 
canula  preserves  the  patient  from  asphyxia,  there  is  serious  cardiac 
inhibition,  perhaps  from  compression  of  nerve  trunks.  All  the 
ligatures  may  be  attached  to  the  upper  border  of  the  sternum,  and 
the  pretracheal  fascia  may  be  anchored  by. a  stitch  to  the  periosteum 
of  the  manubrium.  The  severed  tendons  of  the  sterno-mastoid 
should  be  reunited  by  sutures  and  the  wound  drained  and  sutured. 
Moist  bichloride  gauze  and  frequent  changes  are  advisable,  for  it 
is  extremely  awkward  to  have  an  infected  wound  in  the  medias- 
tinum. Almost  complete  thymectomy  seems  to  have  no  effect 
whatever,  neither  on  blood  nor  on  nutrition. 

ijour.  Am.  Med.  Assn.,  May  25,  1907. 


CHAPTER  XIX 

THE    THORAX 

Its  Anatomy  in  Infancy  and  Childhood — Deformities  of  the 
Thorax — Tumors,  Caries  and  Abscesses  of  Thorax — 
Empyema. 

ITS  ANATOMY   IN    INFANCY    AND    CHILDHOOD 

The  thorax  of  the  infant  differs  in  comparative  size  and  in  shape 
from  that  of  the  adult.  At  birth  the  thorax  is  smaller  than  the 
head,  and  although  with  the  establishment  of  respiration  and  ex- 
pansion of  the  chest,  marked  changes  begin  at  once  to  take  place,  it 
is  not  until  between  the  second  and  third  year  that  the  size  of  the 
thorax  exceeds  that  of  the  head.  And  still  its  changes  of  shape  and 
proportion  are  not  complete,  but  progress  steadily  through  childhood 
and  youth,  unless  checked  or  distorted  by  various  causes  to  be  men- 
tioned presently. 

The  relation  of  the  thorax  to  the  spinal  column  in  the  infant  is 
noteworthy.  Its  uppermost  limit,  the  top  of  the  manubrium  sterni, 
is  usually  at  the  middle  of  the  body  of  the  first  dorsal  vertebra 
(Ballantyne),  while  in  the  adult  it  is  at  the  lower  border  of  the  sec- 
ond dorsal  vertebra.  This  change  is  brought  about  evidently  by  the 
formation  of  the  normal  curves  of  the  spinal  column.  With  growth 
and  development  the  lateral  diameter  of  the  thorax  increases  more 
rapidly  than  the  antero-posterior.  A  cross  section  through  the  in- 
fant's thorax  presents  a  more  circular  form  than  that  of  the  adult. 
Its  antero-posterior  and  lateral  diameters  have  the  proportions  of 
I  to  2.  In  the  period  of  childhood  the  proportions  are  i  to  2^.  In 
the  adult  i  to  3  or  3^.  In  the  young  child  the  lower  part  of  the 
thorax  is  wider,  especially  in  front,  making  room  for  the  large  liver 
and  the  stomach.  In  the  infant  and  young  child  the  ribs  themselves 
are  flatter  and  less  curved,  and  although  ossified  are  comparatively 
soft  and  yielding,  being  especially  compressible  at  the  costochondral 
junctions.  So  yielding  are  the  chest  walls  that  serious  or  even  fatal 
injury  can  be  done  to  their  visceral  contents  without  fracture  or  dis- 
location taking  place,  or  even  contusion  being  visible  externally. 
(See  Sections  on  Fractures  and  Dislocations.) 

DEFORMITIES    OF    THE    THORAX 

Deformity  of  the  thorax  may  be  congenital,  due  to  develop- 
mental error.  For  instance,  in  rare  cases  failure  of  the  visceral 
plates  to  close  may  leave  a  vent  in  the  region  of  the  sternum.  This, 
if  not  too  large,  it  may  be  possible  to  close  by  plastic  operation.    Or 

S12 


THE  THORAX  513 

deformity  may  have  its  origin  in  intra-thoracic  disease  of  the  fetus. 
Or  it  may  come  later  as  a  result  of  atelectasis  pulmonum,  of  rickets, 
spinal  curvature,  pleurisy,  pericarditis,  paralysis,  or  chronic  ob- 
struction of  the  air  passage,  such  as  post-nasal  adenoids  and  enlarged 
tonsils.  Several  instances  of  such  deformities  will  be  found  illus- 
trated under  their  respective  headings,  and  also  in  Figs.  178  and  179. 
One  of  the  most  common  alterations  in  the  shape  of  the  chest  due  to 


Fig.  178.     Deformity  of  thorax  from  rachitis. 

rickets  is  that  commonly  known  as  "  pigeon  breast."  The  softened 
ribs  and  cartilages  are  unable  to  withstand  atmospheric  pressure,  and 
become  flattened  or  depressed,  while  the  sternum,  somewhat  stiffer, 
stands  out  prominently.  Quite  frequently  there  is  more  than  one 
agency  in  the  production  of  the  deformity ;  for  instance,  if  there 
exists,  in  addition  to  rickets,  also  an  obstruction  to  the  inflow  of  air, 
the  deformity  is  greatly  exaggerated ;  and  if  ossification  takes  place 
with  the  parts  in  this  position  it  becomes  permanent.  Another  even 
more  common  type  of  deformity  presents  the  flaring  forward  of  the 
lower  portion  of  the  thorax  due  to  gaseous  distension  of  the  stom- 
ach and  intestines.  This  may  remain  permanently  even  after  the 
cause  no  longer  exists.  The  "  funnel  chest  "  is  still  another  form. 
(Fig.  180.)  Great  care  should  be  taken  to  prevent  these  deformi- 
ties by  removal  of  obstructions  to  free  breathing,  and  attention  to 


514 


SURGICAL    DISEASES    OF    CHILDREN 


the  digestive  organs,  as  well  as  to  the  general  state  of  rachitis,  for 
once  the  deformities  of  sternum  or  ribs  are  fixed  in  hard  bone,  they 
are  well-nigh  unchangeable.  No  band  or  pad  or  brace  of  any  sort 
is  of  any  use  in  overcoming  them.  The  cause,  if  still  existing,  should 
be  removed  and  systematic  breathing  exercises  to  expand  the  chest 
should  be  practiced  many  times  a  day.     Firm  pressure  by  the  hand 

of  the  mother  or  nurse  ap- 
plied over  projecting  parts 
will,  if  persistently  repeated 
several  times  a  day,  aid  in 
the  correction,  especially 
in  infants  and  young  chil- 
dren. Dumbbell  and  wand 
exercises  with  overhead 
movements  simultaneous 
Vv^ith  lung  expansion,  as 
well  as  general  gymnastics, 
hygienic  management,  and 
the  use  of  nutritious  food, 
tonics  and  reconstructive 
agents,  will  promote  more 
vigorous  growth  directed 
into  more  symmetrical  pro- 
portions. 

TUMORS,    CARIES,    AND 
ABSCESS    OF    THORAX 

Tumors  of  the  Thorax 
occasionally  occur  either 
upon  its  walls  or  upon  its 
visceral  contents  or  their 
coverings.  Tumors  of  the 
chest  walls  may  be  fibroma, 
enchondroma,  osteoma,  an- 


FiG.  179.  Rickety  deformity  of  the 
THORAX.  Such  are  usually  superin- 
duced by  adenoids  and  enlarged  ton- 
sils. Fetal  pleurisy  may  cause  similar 
deformities. 


gioma  or  lymphoma ;  although  it  is  very  apt  to  be  sarcoma,  or  a 
tumor  of  mixed  histological  structure  but  malignant  character. 
Tumor  of  lung  or  mediastinum  is  likely  to  be  sarcomatous,  and 
usually  so  obscure  and  so  rapid  in  growth  that  by  the  time  a  diag- 
nosis can  be  made  operation  is  impossible  of  performance  or  hope- 
less. But  if  diagnosis  of  tumor,  even  sarcoma  of  lung  or  rib  or 
any  portion  of  chest  wall  can  be  made  before  inacessible  parts  are 
involved,  it  should  be  removed,  together  with  a  liberal  area  of  sur- 
rounding tissues.  If  this  is  done  early  and  completely  there  may 
be  no  recurrence. 

Caries  of  the  bones  of  the  thorax  may  occur   from  tuber- 
culosis, syphilis,  or  following  trauma.    That  of  the  vertebrae  will  De 


THE    THORAX 


515 


discussed  in  the  chapter  on  the  spine ;  and  tuberculosis  of  the  ribs 
and  sternum  with  diseases  of  bones  and  joints. 

Caries,  of  ribs  may  occur  primarily  or  from  empyema  in  the  at- 
tempt of  the  abscess  to  escape  from  the  chest.  Caries  or  necrosis 
may  result  from  the  pressure  of  a  drainage  tube  after  thoracotomy. 

Syphilitic  disease  should  be  treated  with  iodide  of  potassium, 
and  perhaps  mercury.  With 
caries  or  necrosis  the  dead 
or  diseased  bone  should  be 
removed  and  the  cavity 
packed  with  iodoform 
gauze  until  filled  with 
scar  tissue. 

Infective  Inflamma- 
tion may  lead  to  purulent 
collections  in  the  pleural 
cavity,  the  mediastinum  or 
the  pericardium,  or  the 
abscess  in  the  lung,  or  in 
the  chest  wall,  which  may 
need  sursrical  attention. 


EMPYEMA 

Empyema  is  one  of  the 
commoner  surgical  dis- 
eases of  infancy,  and  par- 
ticularly of  childhood. 

It  differs  in  the  young 
subject  from  the  same  dis- 
ease in  the  adult  in  several 
points,  namely,  its  greater 
frequency,  its  greater  fre- 
quency in  comparison  with 
the  whole  number  of  cases 


Fig.    180.     "  Funnel  chest.' 


of  efifusion  in  pleurisy,  the  greater  obscurity  of  its  symptoms  and 
physical  signs,  its  etiology,  being  less  frequently  due  to  tuberculosis, 
its  greater  damage  to  lung  tissue,  the  greater  deformity  of  thoracic 
walls  and  spine  it  produces  in  certain  cases,  its  greater  fatality  if 
unrelieved  by  operation,  its  behavior  after  aspiration,  and  its  better 
prognosis  if  properly  treated  by  operation. 

No  babe  is  too  young  to  have  purulent  pleurisy,  as  it  can  occur 
in  the  fetus.  Liability  to  the  disease  seems  to  increase  up  to  the 
fourth  year,  when  it  is  at  its  height,  then  diminishing,  slowly  at 
first  but  more  steadily  after  the  fifth  year,  though  it  is  compara- 


5i6  SURGICAL   DISEASES    OF   CHILDREN 

lively  frequent  until  after  ten.  It  may  be  classified  as  primary  and 
secondaryo  It  is  probable  that  with  closer  study  of  cases  the  pri- 
mary list  will  lessen,  being  limited  almost  entirely  to  traumatism  and 
possibly  infection  of  a  pleuritic  effusion,  and  the  secondary  list  will 
increase. 

Malnutrition  and  exposure  to  cold  or  wet  and  lowered  vitality 
from  unsanitary  living  are  predisposing  causes ;  and  any  of  the 
infections  and  eruptive  fevers  render  the  patient  more  liable  to  em- 
pyema, even  if  they  do  not  furnish  the  infecting  organism  found  in 
the  pus.  It  is  apt  to  complicate  or  to  follow  scarlet  fever  or  measles, 
sometimes  influenza,  tuberculosis,  typhoid  or  typhus  fevers,  pertussis 
or  quinsy.  It  may  accompany  retropharyngeal  or  mediastinal,  peri- 
nephric, hepatic  or  post-cecal  abscess,  or  appendicitis,  or  osteomye- 
litis, or  a  purulent  lesion  or  septic  absorption  from  any  part  of  the 
body.  It  is  frequently  secondary  to  an  adjacent  pneumonia,  but 
may  be  also  to  bronchitis  and  even  to  nephritis  or  enteritis.  It  may 
also  occur  in  connection  with  neoplasms  or  actinomycosis  of  pleura 
or  lung. 

An  empyema,  like  a  serous  pleuritic  effusion,  may  be  unilat- 
eral or  bilateral,  and  it  may  be  free  in  the  pleural  sac,  or  confined  by 
adhesions  to  the  diaphragmatic  surface,  to  an  interlobar  fissure  or 
any  large  or  small  area  of  the  pleural  cavity.  It  may  be  a  multilocu- 
lar  abscess  from  subdivision  of  the  pleural  space  formed  by  fibri- 
nous adhesions. 

Morbid  Anatomy. — The  pleura  may  or  may  not  have  undergone 
great  alterations  aside  from  loss  of  its  surface  luster.  Usually  it 
presents  considerable,  and  sometimes  immense,  inflammatory  thick- 
ening. This  may  extend  over  both  visceral  and  parietal  reflections 
of  the  membrane,  although  one  (more  often  the  visceral)  may  be 
more  affected  than  the  other.  Its  surface  is  coated  with  a  fibrinous 
exudate,  which  in  its  coagulation  has  entangled  pus  cells,  leucocytes, 
and  sometimes  bacteria.  In  cases  accompanying  pneumonia  the 
interlobular  connective  tissue  adjacent  is  also  thickened.  If  the 
pleura  be  tuberculous  its  thickening  is  more  marked  at  the  site  of 
the  tubercular  deposits.  In  either  simple  or  tubercular  forms  or- 
ganization of  the  plastic  lymph  or  fibrin  exudate  may  lead  to  adhe- 
sions of  adjacent  membranes,  thus  obliterating  part  of  the  pleural 
cavity  or  producing  sacculation. 

The  fluid  first  effused  may  be  serous  in  character  and  contain 
only  leucocytes  and  endothelial  cells,  or  it  may  be  also  bloody.  Of 
course,  pleurisies  showing  nothing  purulent  are  not  at  the  time  em- 
pyemas, but  if  there  are  present  bacteria  capable  of  producing  pus, 
the  fluid  soon  changes  its  character,  becoming  in  a  few  hours  or  days 
pus  instead  of  serum.  Or  the  fluid  may  be  pus  from  its  first  appear- 
ance and  either  creamy  or  watery  in  consistency,  may  be  yellow, 


THE   THORAX 


517 


clear  or  turbid,  bloody  or  quite  opaque.     It  may  contain  fibrinous 
flakes,  strings,  bands  or  rag-like  pieces. 

The  microscope  may  reveal  in  the  pus  the  diplococcus  lanceo- 
latus  (Frankel's  pneumococcus)   or  the  streptococcus  pyogenes,  or 


Fig.  181.  Maggie  D.  Unusually- 
large  purulent  collection  in  left 
pleural  cavity.  Distention  of 
left  side  of  thorax  easily  no- 
ticeable. Absolute  flatness  on 
percussion  over  entire  left  half, 
and  even  above  the  clavicle. 
Observe  the  complete  oblitera- 
tion of  the  intercostal  spaces : 
also  the  emaciation.  Neverthe- 
less the  patient  was  able  to 
stand  and  even  to  walk  about 
the  room,  such  is  the  tolerance 
that  becomes   established. 


Fig.  182.  Same  case  as  Fig.  181. 
The  distension  of  left  half  of 
thorax  and  obliteration  of  the 
spaces  are  easily  seen.  Also  the 
fullness  above  the  clavicle.  The 
blackened  patch  in  the  right  mam- 
mary region  indicates  the  dullness 
of  the  displaced  heart.  Operated 
at  Cleveland  General  Hospital. 
Patient  entirely  recovered  with 
lung  expanded,  heart  in  normal 
position,  and  no  deformity,  after 
free  drainage  by  resection  of 
small  portion  of  one  rib. 


the  streptococcus  longus,  or  Eberth's  typhoid  bacillus,  or  the  bacillus 
coli  communis,  or  the  staphylococcus  pyogenes  aureus,  or  the  tuber- 
cle bacillus ;  or  two  or  more  varieties  may  be  present  in  the  same 
specimen.  Or  the  pus  may  be  found  free  from  organisms,  which  is 
a  probable  indication  that  the  pleurisy  is  caused  by  the  tubercle 
bacillus. 


5i8 


SURGICAL    DISEASES    OF    CHILDREN 


The  amount  of  pus  may  vary  from  a  few  drachms  to  two  or 
two  and  a  half  pints.  If  the  quantity  of  pus  is  great  the  lung  is 
compressed,  and  this  compression,  together  with  the  hyperplastic 
condition  of  the  interlobular  connective  tissue,  may  cause  it  to  be- 
come solidified  or  carnified  into  a  state  of  permanent  atelectasis. 


Fig.  183.  Empyema  left  side  with 
DISPLACEMENT  OF  HEART.  Measure- 
ment failed  to  detect  difference  be- 
tween the  two  sides,  but  the 
obliteration  of  the  intercostal 
spaces  is  readily  seen.  The  ema- 
ciation in  empyema  resembles  that 
of  phthisis.  Case  referred  by  Dr. 
F.  W.  Hickin. 


Fig.  184.  Same  as  Fig.  183.  Re- 
covered without  deformity  after 
excision  of  rib.  Fever  disap- 
pears on  draining  the  abscess, 
only  recurring  from  blocking 
the  flow  or  complications,  ap- 
petite, digestion  and  assimilation 
improve.  Note  the  _  gain  in 
weight  taking  place  in  a  few 
weeks. 


In  the  ordinary  acute  cases  in  which  compression  of  lung  has  not 
been  too  great  nor  continued  too  long  before  it  was  relieved,  and 
the  lung  retains  a  degree  of  resiliency  and  inflatability,  the  inflam- 
matory exudative  thickening,  both  of  the  pleura  and  interlobular 
connective  tissue,  may  undergo  resolution  and  absorption  and  disap- 
pear or  be  organized  into  new  connective  tissue,  leaving  the  tissues 
normal  or  nearly  so.  Or  a  degree  of  permanent  thickening  of  the 
pleura  and  of  the  deeper  connective  tissues  may  remain^  In  these 
cases  of  lessened  bulk  of  lung,  with  adhesions  of  the  pleural  layers, 


THE    THORAX 


519 


the  affected  side  of  the  thorax  becomes  retracted  and  a  correspond- 
ing curvature  of  the  spine  takes  place. 

Symptoms. — The  symptoms  are  those  of  pleurisy  with  ef- 
fusion. The  condition  may  come  insidiously.  One  has  seen 
children  who  were  going  about  not  supposed  by  their  parents  to 
be  seriously  ailing,  but  languid,  short  of  breath  on  exertion,  fail- 
ing in  appetite,  weight  and 
strength,  and  who,  on  be- 
ing brought  for  examina- 
tion, had  no  history  of 
acute  illness,  but  were 
carrying  a  pint  or  more 
of  pus  in  a  pleural  cavity. 
There  may  be  a  hacking 
cough,  slight  irregular 
fever  and  night  sweats. 
Most  cases  begin  more 
frankly  as  a  pleuro-pneu- 
monia,  sometimes  with 
chill  or  convulsions,  fol- 
lowed by  fever,  102  to  105° 
F.,  a  rapid  pulse,  shallow 
breathing,  breathing  rapid 
out  of  proportion  to  pulse 
rate,  pain  in  the  chest  which 
is  perhaps  referred  to  the 
epigastrium  or  back,  pain 
w^orse  on  coughing,  cough 
which  is  half  suppressed, 
expiratory  moan,  expand- 
ing alse  nasi  and  increas- 
ing dyspnea.  The  patient 
lies  upon  or  bends  toward 
or  presses  upon  the  af- 
fected side.  A  friction  rub 
may  be  heard. 

If  an  effusion  of  consid- 
erable bulk  is  now  poured 
out,  and  especially  if  it 
comes  with  a  degree  of  ra- 
pidity, the  attitude  changes, 

and  the  patient  turns  and  prefers  to  lie  upon  the  back  or  to  be  propped 
up  in  bed  and  avoids  bending  toward  that  side  or  pressing  upon  it. 
Later  on,  tolerance  is  established,  the  dyspnea  becomes  less  marked 
as  long  as  exertion  is  avoided  and  the  patient  returns  to  the  position 
of   lying   on   the   fluid-weighted   side.      With    effusions   of   smaller 


Fig.  185.  Encysted  empyema  left  side 
with  adjacent  portion  of  lung  con- 
solidated. No  bulging  on  affected 
side,  but  retraction,  and  no  obliter- 
ation of  intercostal  spaces,  yet  a  large 
pus  collection  was  found.  Drained 
by  resection.  Mixed  infection.  Slow 
but  complete  recovery.  Boy  aged  5- 
Case  referred  by  Dr.  F.  W.  Hickin. 


520  SURGICAL  DISEASES    OF   CHILDREN 

amount  or  coming  more  gradually,  this  change  of  position  may  not 
take  place.  The  physical  signs  are  well  laid  down  in  many  recent 
text-books  of  medical  pediatrics. 

In  the  presence  of  an  effusion  there  is  impaired  mobility  of  the 
affected  side,  and  if  there  is  a  large  effusion  measurement  shows 
that  side  distended.  The  intercostal  spaces  are  obliterated  and  the 
apex  beat  displaced.  But  I  wish  to  call  attention  to  the  sign  or 
symptom  of  changed  attitude  just  described ;  and  to  the  facts  that 
difference  in  the  two  sides  cannot  always  be  detected  by  measure- 
ment, and  that  there  may  even  be  retraction  and  the  intercostal 
spaces  not  obliterated  on  the  affected  side.     (See  Figs.  i8i  to  185.) 

Fluid  in  the  chest  being  detected,  the  questions  rise,  is  it  serum 
or  pus?  and  shall  it  be  dealt  with  by  mechanical  means  or  by  med- 
icines alone? 

If  the  fluid  has  remained  in  the  chest  several  weeks  after  the 
onset  of  the  illness  it  is  more  apt  to  be  purulent.  If  there  had  been 
a  preceding  attack  of  scarlet  fever,  measles,  whooping-cough  or  any 
other  eruptive  or  infectious  disease,  the  likelihood  of  pus  is  increased. 
Chills  or  chilliness,  intermittent  fever  with  exhaustive  sweats, 
clubbed  finger  ends  and  progressive  emaciation  point  to  suppura- 
tion. The  emaciation  in  empyema  resembles  that  of  phthisis.  Leu- 
cocytosis  indicates  a  suppuration.  Edema  of  the  chest  wall  not  only 
betrays  the  presence  of  pus  within,  but  that  nature  will  endeavor  to 
discharge  it  by  perforation. 

A  neglected  empyema  may,  if  it  be  small  or  even  large,  possibly 
have  its  fluid  portions  absorbed  and  its  more  solid  elements  become  a 
cretaceous  mass.  However,  the  possibility  of  this  rare  and  not  very 
desirable  event  is  by  no  means  to  determine  our  course  of  treatment. 
The  pleural  pus  collection  may  break  through  the  chest  wall  at  about 
the  fourth  or  fifth  intercostal  space  and  discharge  itself.  It  may 
break  into  a  bronchus  and  be  gradually  emptied  by  coughing.  It 
may  burrow  into  the  lung  and  form  abscess  there,  possibly  discharg- 
ing thence  into  a  bronchus.  It  may  burrow  through  the  diaphragm 
and  cause  peritonitis,  or  on  the  right  side  abscess  of  the  liver,  or  it 
may  track  dowmward  and  appear  as  a  lumbar  abscess. 

Treatment. — The  medical  treatment  of  pleurisy  is  well  laid  down 
in  excellent  text-books  on  medical  pediatrics,  and  the  physician  may 
himself  choose  to  aspirate  for  diagnostic  or  curative  purposes,  be 
the  effusion  serous  or  purulent.  But  the  surgeon  is  frequently  called 
in  the  purulent  cases,  or  cases  suspected  of  purulence,  and  must  be 
familiar  with  the  disease  and  the  surgical  measures  advisable.  I 
may  be  allowed  to  remark  in  passing  that  if  physicians  would  more 
freely  resort  to  the  use  of  the  aspirator  in  the  serous  effusions  which 
are  very  large  in  quantity,  without  waiting  many  weeks,  as  is  often 
done,  while  the  lung  is  compressed,  hoping  by  medicines  alone  to 


THE  THORAX  521 

produce  a  reabsorptlon  of  the  fluid,  their  results  would  be  far  better. 
Probably  three  weeks  is  quite  long  enough  to  wait  before  resorting 
to  mechanical  means  for  the  removal  of  fluid  from  the  pleural  cav- 
ity, and  it  would  often  be  better  to  aspirate  sooner.  The  effusion 
may  be  purulent  from  the  first  and  require  prompt  removal ;  or  even 
if  it  is  only  serous  its  presence  not  only  embarrasses  the  respiration 
but  damages  the  lung,  more,  the  longer  its  compressing  effect  exists, 
while  its  removal  by  aspiration  is  a  very  simple  process.  (38) 

Paracentesis  Thoracis. — To  Bowditch  of  Boston  we  are  in- 
debted for  the  use  of  suction  to  remove  fluid  from  a  cavity.  Para- 
centesis thoracis  for  diagnostic  purposes  may  be  done  with  a  hypo- 
dermic syringe  fitted  with  a  long  needle,  if  no  better  instrument  is 
available.  But  failing  to  draw  fluid  with  such  an  instrument  would 
not  prove  its  absence,  for  very  frequently  the  fluid  would  not  run 
through  so  fine  a  needle.  An  exploring  needle  at  least  a  millimetre 
in  caliber  fitted  with  a  syringe  holding  an  ounce  or  two  is  better 
suited  for  the  work.  But  one  prefers  for  either  diagnostic  or  thera- 
peutic use  a  trocar  and  canula  as  less  likely  to  injure  expanding 
lung  and  less  apt  to  be  obstructed  by  flakes  of  pus  or  fibrinous 
masses.  To  the  canula  should  be  attached  the  Dieulafoy  or  similar 
apparatus.  Then  one  is  prepared  not  only  to  find  but  to  remove 
the  fluid.  If  an  aspirating  syringe  is  used  a  few  inches  of  rubber 
tubing  should  intervene  between  needle  and  syringe. 

The  instruments  should  be  rendered  aseptic  by  boiling.  The 
patient  should  be  held  by  nurse  or  parent  so  securely  that  he  cannot 
interfere  with  the  surgeon  and  that  no  sudden  twist  may  snap  the 
needle  as  it  is  introduced. 

The  needle  or  trocar  may  be  introduced  into  almost  any  part 
of  the  chest,  avoiding,  of  course,  the  heart  and  great  vessels  near  it 
and  near  the  roots  of  the  lungs,  the  liver,  and  the  vessels  and  nerves 
near  the  spinal  column.  The  site  of  puncture  should  be  where  per- 
cussion reveals  the  greatest  flatness.  If  the  whole  side  is  flat,  the 
sixth  space  on  the  right  and  sixth  or  seventh  on  the  left  in  mid- 
axillary  or  posterior  axillary  line  are  favorite  sites  for  puncture. 
The  skin  should  be  carefully  washed  with  soap  and  warm  water 
and  a  piece  of  gauze,  then  with  ether  or  alcohol,  followed  by  bichlo- 
ride solution  (i  :200o)  and  sterile  water.  No  anesthetic  is  necessary, 
but  ethyl-chloride  spray  or  a  piece  of  ice  may  be  used.  Avoiding  the 
ribs,  the  needle  is  thrust  in  a  distance  of  i^  to  3  centimetres  {-l  to 
ij  inches)  unless  fluid  is  encountered  sooner.  As  soon  as  the 
needle  has  been  introduced  it  is  held  loosely  in  the  hand,  which  stead- 
ies itself  against  the  thorax  and  follows  any  movement  of  the  pa- 
tient. If  fluid  is  not  encountered,  the  needle  should  not  be  pointed 
in  this  or  that  direction  in  search  of  it.  Such  maneuvers  may  wound 
the  lung  or  break  the  needle.     If  the  fluid  does  not  flow  or  flows  a 


522  SURGICAL   DISEASES    OF    CHILDREN 

little  and  soon  stops,  it  may  be  because  it  is  too  thick  or  the  needle 
may  be  clogged  with  a  flake  of  pus  or  fibrin.  If  trocar  and  canula 
have  been  used,  the  trocar  or  a  blunt  wire  (previously  sterilized) 
passed  through  the  canula,  may  remove  the  obstruction.  Or  the 
needle  or  canula  may  impinge  on  expanding  lung  or  rising  dia- 
phragm, which  stops  the  flow,  and  a  partial  withdrawal  may  free  it. 
The  emptying  of  the  distended  pleura  may  embarrass  the  circula- 
tion and  excite  troublesome  coughing.  This  may  be  relieved  by 
stopping  the  flow  for  a  half  minute,  or  by  drawing  tighter  a  double- 
tailed  bandage  passed  round  the  chest  to  control  expansion.  Per- 
sistent coughing  is  an  indication  to  discontinue  the  aspiration.  It 
is  not  advisable  in  all  cases  to  draw  off  at  one  time  the  whole  of  a 
large  effusion.  Suction  having  stopped,  the  needle  is  withdrawn 
with  one  quick  movement.  The  skin  puncture  is  covered  with  iodo- 
form collodion,  or  a  bit  of  iodoform  gauze  held  in  place  with  a  patch 
of  adhesive  plaster.  A  specimen  of  the  fluid  should  be  subjected 
to  bacteriological  examination. 

Cases  are  on  record  in  which  a  single  tapping  or  repeated  tap- 
pings, particularly  if  the  pus  contained  only  pneumococci,  have 
cured  empyema,  but  such  a  result  is  not  to  be  waited  for  and  does 
not  alter  the  rule  that  if  the  collection  is  purulent  no  time  should  be 
lost  in  securing  free  drainage. 

Drainage. — Methods  of  drainage  depending  on  needles  or  ca- 
nulae  thrust  through  the  chest  wall  and  left  for  hours  or  days  in  that 
position  are  hard  to  manage  and  unsatisfactory.  Losing  no  time  in 
effecting  free  drainage  does  not  mean  that  an  opening  by  incision 
must  be  made  at  the  same  sitting  with  the  aspiration.  Indeed,  it  may 
be  advisable  to  wait  some  hours  or  even  a  few  days,  especially  if 
there  has  been  much  tension  within  the  thorax  and  the  needle  has 
removed  a  large  amount  of  fluid,  in  order  that  expansion  of  the 
lung  may  take  place  gradually.  But  a  free  opening  must  not  be 
long  delayed. 

Thoracotomy. — Thoracotomy  having  been  decided  upon,  there 
is  a  choice  between  a  simple  incision  through  an  intercostal  space  and 
excision  of  a  portion  of  a  rib.  The  simple  incision  has  the  advantage 
of  being  a  slighter  operation  and  more  quickly  performed,  therefore 
producing  less  shock,  and  not  always  requiring  general  anesthesia. 
It  has  the  disadvantage  of  not  making  an  opening  sufficiently  large 
for  easy  exploration  of  the  abscess  cavity ;  that  the  margins  of  the 
ribs  impinge  upon  the  drainage  tubes  and  interfere  with  free  drain- 
age ;  that  the  pressure  of  the  tubes  is  apt  to  cause  necrosis  of  rib ; 
and  that  it  is  often  difficult  to  prevent  the  incision  from  healing  shut 
before  the  abscess  cavity  has  been  obliterated  by  expansion  of  the 
compressed  lung  and  also  of  the  sound  lung,  by  depression  of  the 
chest  wall  and  rising  of  the  diaphragm. 


THE    THORAX 


523 


Excision  of  a  portion  of  rib  has  the  advantage  that  it  produces 
an  opening-  into  which  an  exploring  finger  may,  if  necessary,  be  in- 
troduced, in  which  the  drainage  tube  rests  easily,  and  remains  patu- 
lous and  is  not  so  apt  to  produce  rib  necrosis;  an  opening  through 
which  fibrinous  masses  may 
be  easily  removed;  an  open- 
ing which  remains  open 
longer,  although  it  has  a  con- 
stant tendency  to  close  pre- 
maturely. It  has  the  disad- 
vantage of  usually  requiring 
general  anesthesia  during  its 
performance  of  being  more' 
severe  than  simple  incision — • 
too  severe  for  very  young  or 
greatly  enfeebled  patients ; 
and  that  it  produces  greater 
scar,  though  it  does  not,  as 
has  been  stated  by  some,  pro- 
duce chest  deformity  unless 
a  considerable  portion  of  a 
rib  or  of  several  ribs  be  ex- 
cised.   (Fig.  1 86.) 

As  a  general  rule  simple 
incision  is  usually  chosen  for 
patients  under  eighteen 
months  of  age,  and  for  those 
very  greatly  enfeebled  or  in 
whom  a  heart  lesion  or  other 
complication  forbids  general 
anesthesia.  It  is  only  under 
readily  be  done  with  ethyl- 
chloride  spray,  or  cocaine, 
the  former  being  preferable, 
though  general  anesthesia  is 
sometimes  used.  Excision  is 
usually  done  under  general 
anestehsia.     It   is   only  under 


Fig.  i86.  Whooping  cough,  measles, 
and  pleuro-pneumonia  with 
EMPYEMA  at  the  age  of  6i  years. 
Drainage  by  excision.  Pds  showed 
pneumococci  and  tubercle  bacilli. 
Photograph  2  years  after,  shows 
no  deformity  as  some  assert  oc- 
curs after  excision,  and  that  re- 
covery can  follow  pleurisy  with 
tubercle   bacilli   present. 


exceptional  conditions  that  it 

should  be  done  with  local  anesthesia,  although  this  when  necessary 

is  practicable. 

The  operation  of  thoracotomy  for  empyema  is  performed  as 
follows :  The  side  of  the  chest  to  be  opened  is  cleansed  with  soap 
and  warm  water,  followed  by  alcohol  or  ether,  bichloride  solution 
(i  to  2000 ),  and  finally  sterile  water. 


S24  SURGICAL   DISEASES    OF   CHILDREN 

It  is  generally  advised  to  aspirate  just  before  proceeding  to  cut 
into  the  chest,  even  though  an  aspiration  had  been  made  a  few  days 
previously.  But  if  the  aspiration  had  been  made  only  a  few  hours 
or  a  day  previously  to  the  operation,  there  can  be  no  advantage  in 
using  the  needle  again  unless  there  be  much  tension.  If  the  fluid 
in  the  chest  is  producing  a  great  amount  of  pressure  as  evidenced 
by  the  respiration  rate  and  the  physical  signs,  there  is  an  advan- 
tage in  its  gradual  removal  by  the  aspirator,  even  though  aspiration 
is  immediately  followed  by  a  free  opening.  By  so  doing  there  will 
be  less  coughing  and  embarrassment  of  respiration  and  circulation 
than  if  the  tension  is  suddenly  relieved  by  rapid  escape  of  the  pus 
through  a  larger  opening.  For  the  same  reason  the  drainage  tubes, 
sterilized,  and  also  a  pad  of  bichloride  gauze  and  cotton  should  be 
ready  at  hand  before  the  knife  is  used. 

If  a  simple  incision  has  been  decided  upon,  it  is  situated  in  the 
intercostal  space,  is  from  an  inch  and  a  quarter  to  an  inch  and  three- 
quarters  long,  and  carried  through  skin,  fascia  and,  perhaps,  mus- 
cles. In  cutting  between  the  ribs,  one  should  avoid  injuring  the 
periosteum  of  the  rib  below  the  incision  and  keep  clear  of  the  artery 
and  nerve  which  run  along  the  inferior  edge  of  the  rib  above  the 
incision.  If  preferred,  after  the  skin  and  fascia  have  been  incised, 
a  grooved  director  may  be  thrust  in,  followed  by  a  hemostat  or  a 
pair  of  round-pointed  scissors  closed,  by  spreading  the  blades  of 
which  the  opening  may  be  enlarged  to  admit  the  drainage  tubes. 
It  is  generally  not  ea.sy  to  introduce  an  exploring  finger  between  the 
ribs  unless  the  incision  is  larger  than  is  really  necessary  for  drainage. 

If  a  portion  of  one  rib  is  to  be  excised,  one  selects  the  site  of 
operation  by  the  same  rule  as  that  for  aspiration  or  incision,  going 
in  at  point  of  greatest  dullness.  With  a  large  collection  free  in  pleu- 
ral cavity  one  chooses  the  mid-axillary  or  posterior  axillary  line  just 
in  front  of  the  latissimus  dorsi  muscle,  not  lower  than  the  sixth  rib 
on  the  right  and  sixth  or  seventh  on  the  left  side.  In  small  saccu- 
lated collections  one  usually  takes  the  shortest  route.  In  the  case 
of  a  girl  who  had  a  circumscribed  collection  of  pus  behind  the  upper 
portion  of  the  right  mammary  gland,  I  chose  to  make  an  opening 
in  the  fold  beneath  the  gland,  and,  tearing  through  the  adhesions  in 
an  upward  direction,  drained  the  pus  cavity  and  avoided  a  more  con- 
spicuous scar.     (Case  operated  for  Dr.  I.  S.  Bretz.) 

The  incision  corresponds  to  the  center  of  the  rib  and  is  carried 
down  to  and  through  the  periosteum  and  an  inch  and  a  half  or  two 
inches  long.  One  or  two  small  vessels  may  need  forceps.  The  peri- 
osteum is  next  separated  from  the  bone,  a  dissector  being  most  con- 
venient for  the  edges  and  going  beneath  the  bone,  which  is  laid  bare 
a  distance  of  an  inch  or  an  inch  and  a  half  (25  to  38  mm.)  (39). 
A  piece  of  the  rib  of  that  length  is  then  removed,  the  anterior  cut 


THE   THORAX  525 

being  made  first.  In  using  the  ordinary  bone  forceps  it  will  some- 
times occur  that  the  point  beneath  the  rib  will  puncture  the  cavity 
prematurely.  Therefore,  if  a  gouge  forceps  or  bone  shears  be  used 
to  make  the  section,  the  work  is  neater.  The  cut  ends  of  bone  should 
be  freed  of  splinters  or  sharp  corners,  and  the  cavity  entered  in  the 
middle  of  the  exposed  posterior  layer  of  periosteum  by  a  grooved 
director  or  pointed  hemostat  followed  by  finger.  I  am  fond  of 
making  with  the  entering  finger  a  hasty  exploration  as  to  the  size 
and  shape  of  the  cavity  and  resilience  of  the  lung  adhesions,  etc., 
but  not  necessarily  to  break  up  adhesions.  If  the  child  be  much 
weakened  this  exploration  should  not  be  made.  If  there  be  found 
large  fibrinous  clots  or  masses  obstructing  the  flow,  and  if  the  child's 
condition  warrant  the  manipulation,  they  may  be  removed  with  for- 
ceps or  finger.  As  a  general  practice  irrigation  is  not  advised.  It 
may  cause  shock  and  has  caused  death.  It  is  better  reserved  for  fetid 
cases.  In  the  usual  case  the  tube  or  tubes  should  be  immediately 
inserted  into  the  opening,  covered  promptly  with  the  pad  and  binder, 
the  child  turned  upon  his  back  and  the  binder  pinned  rather  snugly. 

Dressing  will  probably  be  required  in  eight  or  twelve  hours, 
but  after  once  or  twice  repeating  at  this  interval  it  may  go  twenty- 
four  hours.  Sterile  absorbent  cotton  between  layers  of  gauze,  or, 
better  still,  prepared  oakum  or  jute  covered  with  gauze  constitute 
the  dressing  material.  Irrigation  at  the  time  of  the  dressing  is 
not  generally  necessary  unless  the  pus  is  foul  at  the  time  of  opera- 
ation  or  become  so  later,  which  should  be  prevented  by  careful 
dressing.  Irrigation  in  dressing  may  cause  as  much  shock  as 
operation.  It  sometimes  produces  a  rise  of  temperature  appar- 
ently brought  about  by  increased  absorption  of  toxines.  As  before 
stated,  irrigation  should  be  reserved  for  fetid  cases,  and  this  provided 
the  opening  is  not  sufficiently  large  that  the  cavity  can  be  packed  dry 
with  iodoform  and  sterile  gauze.  (40) 

Care  should  be  taken  that  the  drainage  tubes  are  not  too  long, 
and  especially  that  they  do  not  impinge  on  the  expanding  lung.  If 
the  tube  or  tubes  reach  fairly  within  the  pleural  cavity  it  is  sufficient. 
To  find  the  tube  displaced  from  the  incision  may  indicate  that  it 
has  been  thrust  out  by  the  expanding  lung.  Neither  should  the 
outer  end  of  the  tube  project  far  from  the  skin  surface.  Many  in- 
genious contrivances  have  been  made  for  drainage  tubes  in  em- 
pyema ;  by  wiring  or  suturing  the  rubber  tubing  to  a  flat  rubber 
sheet  through  which  it  has  been  thrust,  or  to  a  split  piece  of  similar 
tubing,  and  the  like.  But  that  most  easily  prepared  is  made  by 
pinning  together  with  a  safety-pin  two  or  three  pieces  of  tubing  of 
the  caliber  of  a  cedar  pencil,  one  piece  being  fenestrated.  When  in 
place  the  pin  lies  across  the  wound  and  prevents  the  drains  from' 
slipping  into  the  cavity.    In  dressing,  a  piece  of  folded  gauze  should 


526 


SURGICAL   DISEASES    OF   CHILDREN 


be  placed  beneath  the  ends  of  the  pm.  A  better  device  is  the  eyelet- 
shaped  drainage  tube  made  of  soft  rubber.  (See  Fig.  187.)  It  is 
known  as  the  Flint  empyema  tube.  The  wider  flange  is  left  outside. 
•With  this  tube  there  is  no  chance  of  thrusting  an  end  against  ex- 
panding lung,  and  no  pain  incident  to  replacing  a  tube  which  has 
been  let  slip  out.  The  only  objection  to  it  is  that  on  final  removal 
of  the  tube  there  is  a  certain  amount  of  pain,  and  maybe  some  little 
bleeding  from  granulations.  The  tubes  are  made  single  or  double 
and  in  various  lengths,  from  half  an  inch  to  two  inches. 

The  opening  will  continue  to  discharge  very  freely  for  days 


Fig.    187.      Flint    empyema    drainage    tubes.     The    wider    flange    is     left 
outside    the    thoracic    wall. 


and  less  freely  for  several  weeks,  lessening  gradually.  A  sudden 
stoppage  of  the  flow  by  a  plugged  drainage  tube  will  be  promptly 
followed  by  a  rise  in  temperature. 

The  expansion  of  lung  that  is  the  great  desideratum  may  take 
place  to  a  degree  as  soon  as  the  chest  is  opened.  But  a  failure  to 
expand  noticeably  at  that  time  or  even  in  a  few  days  subsequently 
should  not  be  regarded  as  discouraging.  Remarkable  expansion  may 
occur  many  days  after  the  pressure  is  released,  and  sometimes  it 
appears  to  come  rather  suddenly  after  long  delay.  Expansion  should 
be  promoted  by  breathing  exercises,  laughing,  crying,  singing,  blow- 
ing soap  bubbles,  or  wind  instruments,  or  the  apparatus  devised  by 
James  with  which  the  child  is  induced  to  blow  colored  fluid  from 
one  bottle  into  another.  No  class  of  patients  more  imperatively 
requires  good  ventilation,  or,  if  possible,  life  out  of  doors  in  all  but 
positively  inclement  weather.  When  the  cavity  has  shrunk  in  its 
dimensions,  the  discharge  has  become  serous  and  small  in  amount, 
one  of  the  drainage  tubes  may  be  removed ;  and  when  the  discharge 
is  no  greater  than  would  be  caused  by  the  presence  of  the  drainage 
tube,  the  latter  may  be  removed  entirely,  the  sinus  being  filled  with 
antiseptic  gauze  at  each  dressing,  until  this  also  is  crowded  out  by 
the  healing  process. 


THE    THORAX 


527 


After  several  weeks,  if  the  discharge  has  diminished  to  a  very 
small  amount,  and  the  opening  has  lessened  to  a  mere  sinus,  and 
such  a  sinus  refuses  to  heal,  and  if  no  cavity  within  the  chest  is  to 
be  found  by  probing,  it  may  be  that  a  portion  of  the  rib  has  necrosed. 
This  may  take  place  either  following  simple  incision  or  excision  of 
rib,  more  frequently  the  former.  In  incision  cases  it  is  the  edge 
of  a  rib  which  becomes  necrotic ;  in  excision  cases  one  of  the  cut 
ends.  The  sequestrum  should  be 
removed  even  though  it  may  re- 
quire, as  it  probably  will,  anes- 
thesia and  a  dissection  in  order 
to  do  so. 

Thoracoplasty. — In  cases 
in  which  a  cavity  remains,  the 
fault  lies  not  in  the  unhealthy 
condition  of  its  lining.  So  that 
irrigation  with  a  solution  of  bi- 
chloride of  mercury,  or  carbolic 
acid,  or  boracic  acid,  or  iodine, 
or  permanganate  of  potash,  or, 
worst  of  all,  hydrogen  peroxid, 
which  have  been  used  with  the 
idea  of  promoting  granulation, 
are  useless  or  harmful.  To  close 
a  cavity  of  any  considerable  size, 
the  lung  and  chest  wall  must 
meet  either  by  expansion  of  the 
former  or  collapse  of  the  latter, 
together  with  expansion  of  the 
opposite  lung  and  elevation 
of  the  diaphragm.  Operations 
either  to  rernove  the  adhesions 
binding  down  the  lung  or  to  col- 
lapse the  chest  wall  are  not  to 
be  undertaken  without  due  con- 
sideration, and  yet,  as  the  alternative  is  a  continued  suppuration  with 
hectic  fever  and  exhaustion  or  lardaceous  disease,  they  are  to  be 
urged  and  performed  in  all  suitable  cases.     (See  Fig.  i88.) 

When  further  expansion  of  lung  is  impossible  by  reason  of  its 
carnified  condition  or  immovable  adhesions,  it  is  necessary  to  col- 
lapse the  chest  wall  by  excising  portions  of  several  ribs,  usually  the 
sixth  and  fifth,  sometimes  also  the  fourth,  and,  if  necessary,  from 
the  third  to  the  eighth  or  ninth  inclusive,  though  this  extensive  re- 
section is  seldom  required  in  children.  The  number  of  the  ribs 
and  the  length  of  the  pieces  to  be  excised  should  be  such  as  the 
surgeon  judges  sufficient  to  enable  the  chest  wall  to  be  depressed 


Fig.  iS8.  Johnny  F.,  aged  ii  years. 
After  excision  of  rib  for  drain- 
age of  empyema.  The  lung  fail- 
ing to  expand  sufficiently,  a 
cavity  and  sinus  persisted,  re- 
quiring more  extensive  resection. 


528 


SURGICAL   DISEASES    OF   CHILDREN 


inward  far  enough  to  meet  the  lung,  and  may  vary  from  one  to  three 
inches,  or  may  be  from  the  cartilage  to  the  tubercle  of  the  rib  or 
ribs  removed.  (See  Fig.  189.)  As  a  rule,  the  pieces  of  rib  removed 
should  be  the  greater  part  of  an  inch  longer  than  the  diameter  of 

the  cavity;  and  care  should  be 
taken  to  remove  as  much  from 
the  upper  as  from  the  lower  ribs. 
The  position  of  the  cavity  will 
also  be  considered  in  selecting 
'the  portions  to  be  removed. 
'Usually  they  are  in  the  axillary 
line.  The  sinus  locates  the  center 
of  the  first  incision  and  a  single 
rib  is  excised  as  above  described. 
The  extent  of  the  cavity  can  then 
be  ascertained  and  portions  of 
other  ribs  be  removed  as  neces- 
sary. If  the  first  incision  be 
through  an  intercostal  space,  two 
ribs  can  readily  be  excised 
through  the  same  incision  by  re- 
flecting the  skin-flaps.  If  it  is 
necessary  to  excise  other  ribs,  a 
second  incision  can  be  made  at 
right  angles  through  the  center 
of  the  first.  Or  an  incision  at 
each  end  of  the  first  extended 
either  upward  or  downward  or 
both  ways  will  permit  adequate 
flaps  to  be  raised  or  turned  down 
and  the  ribs  exposed. 

Extensive  excision  of  ribs  for 
the  cure  of  empyema  is  generally 
known  as  Estlander's  operation, 
he  having  published  a  paper  on 
the  subject  (in  1879),  although 
it  was  previously  done  by  De 
Cerenville  (1876)  and  others.  In 
this  connection  the  following  is 
of  interest:  "  An  idea  has  generally  prevailed  among  surgeons  that  if 
the  pleura  costalis  were  divided  in  the  living  subject,  the  lung  would 
immediately  collapse,  as  it  is  usually  found  to  do  in  the  dead  one. 
But  ]\I.  Bremond  ^  has  shown  by  experiments  that  not  only  when 


Fig.  189.  Same  case  as  188, 
at  the  age  of  18,  seven  j-ears 
after  resection  of  15  inches  of 
ribs.  Retraction  of  thoracic 
wall  and  spinal  curvature. 
Gj^mnastics  rather  than  sup- 
porting apparatus  are  advised 
in   such   conditions. 


1  Memoirs  L'Acad.  Des  Sciences,  1739. 


THE   THORAX  529 

an  opening  is  made  into  the  cavity  of  the  thorax,  but  even  when 
some  of  the  ribs  are  removed  the  lungs  will  occupy  their  natural 
situation,  and  are  even  thrust  up  into  the  opening  during  expiration. 
Mr.  Norris  ^  has  also  lately  shown,  by  experiments  undertaken  for 
this  purpose,  as  well  as  by  observations  upon  the  effects  of  acci- 
dents, that  frequently  the  lungs  do  not  collapse  when  the  cavity  of 
the  chest  is  exposed  in  the  living  animal.  And  I  have  also  had  oc- 
casion to  observe,  on  dividing  the  pleura  costalis  in  a  case  of  sup- 
posed hydrothorax  (in  which,  however,  no  water  was  found),  that 
the  exposed  lung  did  not  collapse,  a  circumstance  which,  I  think, 
ought  to  encourage  us  to  a  more  frequent  performance  of  such  an 
operation.  In  other  experiments,  however,  the  lungs  have  been 
known  to  collapse,  and  the  circumstances  on  which  either  of  these 
effects  depend  are  not  perhaps  well  understood.-  Estlander  excised 
only  the  ribs,  leaving  the  remainder  of  the  chest  wall,  including,  as 
it  does  in  many  cases,  an  immensely  thickened  costal  pleura  capable 
of  doing  a  great  deal  to  prevent  collapse  of  the  chest  and  healing  of 
the  cavity.  While  in  some  instances  the  periosteum  will  so  quickly 
reproduce  bone  that  the  condition  is  much  the  same  as  before  opera- 
tion, the  newly  formed  bone  propping  the  chest  w^all  before  collapse 
is  completed. 

For  use  in  these  cases  of  long  standing,  where  there  is  unex- 
panded  lung,  a  cavity  of  considerable  size  with  greatly  thickened 
chest  walls,  Schede  ^  devised  and  practiced  an  operation  which  since 
bears  his  name.  Schede's  operation  differs  from  Estlander's  in  that 
not  only  the  ribs  but  the  periosteum  and  intercostal  muscles  and 
thickened  costal  pleura  also  are  removed.  The  technique  is  as  fol- 
lows :  The  incision  begins  on  the  front  of  the  chest  at  the  level  of 
the  axilla,  extends  downward,  curving  backward  to  the  lower  limit 
of  the  pleural  cavity,  thence  curving  upward  posteriorly  to  the  level 
of  the  second  rib  between  the  scapula  and  the  spine.  The  flap,  con- 
sisting of  all  the  soft  parts  down  to  the  ribs  and  including  the  scap- 
ula, is  then  raised.  Each  rib  is  then  divided  in  the  center,  each'  end 
caught  with  bone  forceps  and  the  rib  broken  out  to  the  tubercle 
posteriorly  and  to  the  costal  cartilage  anteriorly,  the  remaining 
structures  of  the  chest  well  sheared  through  and  removed.  The 
intercostal  arteries  are  clamped  and  tied  if  necessary.  The  visceral 
pleura  is  then  thoroughly  curetted  and  the  flap  applied  to  its  surface 
and  sutured  in  place,  all  but  the  lowest  point  for  drainage,  and  union 
by  first  intention  is  expected. 

Keene  practiced  and  published  *  in  this  country  an  operation 

1  Memoirs   Med.    Soc.   of  London,   Vol.    IV.,   p.  440. 
-Surgical  Works  of  John   Abernethy,   F.   R.   S.,  Vol.   U.,  p.    181,  Lon- 
don,  1822. 

3  Verhandl.   d.  Cong.  Innere.  Med.  Wiesb.,   1890,  Vol.   IX.,  p.  41. 
*  Annals  of  Surg.,  June,  1895. 


530  SURGICAL   DISEASES    OF   CHILDREN 

practically  the  same  as  Schede's,  without  knowing-  of  Schede's  pre- 
ceding publication.  Keene's  operation  differs  from  Schede's  in  that 
he  does  not  first  excise  the  ribs  and  then  the  pleura,  but  divides 
the  entire  chest  wall  under  the  soft  parts  with  a  strong  pair  of 
bone  pliers. 

Many  modifications  of  this  operation  have  been  made.  The  flap, 
instead  of  being  horseshoe-shaped,  may  consist  of  a  triangle  or  of 
two  triangles,  the  incision  having  been  shaped  like  a  capital  L  or  like 
an  inverted  T  (±),  with  the  transverse  incision  on  the  lowest  rib 
to  be  resected,  and  the  vertical  incision  in  the  axillary  line.  Or  it 
may  be  H  shaped,  with  two  rectangular  flaps.  The  ribs  may  be 
sawed  (a  needlessly  slow  process).  The  pleural  cavity  may  be 
scraped,  or  be  "  peeled  "  with  the  aid  of  scissors. 

All  operators  will  probably  agree  with  Gerster  that  this  opera- 
tion is  one  of  great  danger  on  account  of  shock  and  depression  from 
the  profuse  hemorrhage.  It  is  quite  a  bloody  operation,  especially 
when  decortication  is  also  done,  although  not  always  accompanied 
by  the  amount  of  hemorrhage  one  would  expect  from  the  normal 
size  of  the  numerous  vessels  divided,  as  the  previous  inflammation 
may  have  occluded  them,  and,  as  Keene  remarks,  the  crushing  of  the 
pliers  may  prevent  the  hemorrhage.  An  assistant  diligent  in  the  use 
of  hot  gauze  pads  or  towels  may  prevent  extensive  hemorrhage  from 
the  large  surfaces  exposed  and  which  cannot  be  clamped,  while  the 
operator  proceeds  rapidly  to  complete  his  work.  The  cavity,  after 
its  surface  has  been  covered  with  iodoform  gauze,  is  usually  packed 
with  sterile  gauze.  The  skin  flaps  are  placed  over  the  dressing  and 
all  margins  not  needed  for  drainage  are  coapted  and  sutured.  Heal- 
ing by  adhesion  of  granulating  surfaces  is  more  frequently  obtained 
than  by  first  intention. 

Delorme^  cut  through  the  whole  chest  wall,  including  skin, 
muscles,  ribs  and  costal  pleura,  and  through  this  extensive  door  re- 
moved the  thickened  masses  from  the  visceral  pleura.  The  flap  was 
then  replaced  and  closure  of  the  cavity  by  expansion  of  the  lung 
was  expected.  If  the  lung  then  failed  to  expand,  the  result  of  the 
operation  was  a  failure.  This  operation  of  decortication  without 
sacrifice  of  a  portion  of  the  chest  wall,  or  at  least  portions  of  the 
ribs,  has  not  been  found  effective  by  many  operators. 

These  extensive  resections  are  only  to  be  undertaken  in  ob- 
stinate cases  and  in  older  children,  and  after  careful  examination 
for  amyloid  changes  and  nephritis.  They  are  very  badly  borne  in 
young  children,  often  proving  fatal  in  those  under  two  years  of 
age.  Fortunately,  in  infants,  owing  to  their  readily  yielding  chest 
walls,  even  Estlander's  operation  is  very  seldom  required.    If  para- 

1  Gazette  d.  Hop.  Par.,  1894.    LXVIL,  94,  96.     Nouveau  Traitement  des 
Empyemes  Chroniques. 


THE  THORAX  531 

Jaboulay's  operation,  separating  six  or  seven  of  the  upper  ribs  from 
the  sternum  has  not  displaced  Estlander's  operation. 

Double  empyema  may  occur,  and  when  it  does  it  doubles  the 
necessity  of  prompt  surgical  interference.  Aspiration  should  be 
done  first  and  may  be  performed  upon  both  sides  at  the  same  sit- 
ting; a  few  days  later  a  free  incision  or  excision  is  made  upon  one 
side  and  an  interval  of  some  days  should  elapse  before  the  other  side 
is  operated  upon. 

Bismuth  paste  injection  ^  has  gained  recognition  as  a  method 
of  treating  suppurating  cavities  and  sinuses  remaining  in  empyema, 
lung  abscess ;  Pott's  disease,  and  other  fistulous  tracts  and  abscess 
cavities,  superior  to  previous  methods  of  injecting  hot  vaseline, 
parafine,  etc.  Used  promptly  it  may  preclude  thoracoplasty  or  it 
may  successfully  follow  Estlander's,  Schede's  and  other  operations 
that  fail  to  close  the  cavity.  The  paste  ordinarily  used  is  one  part 
bismuth  subnitrate  or  subcarbonate,  to  two  parts  sterile  yellow  vase- 
line ;  but  it  may  be  diluted  as  low  as  five  parts  bismuth  to  ninety- 
five  parts  vaseline.  From  a  few  drachms  to  several  ounces  of  this 
paste,  warmed  to  fluidity,  are  injected  into  the  cavity  with  a  piston 
syringe.  Bronchial  communication  is  no  contra  indication.  The 
effect  is,  that  the  pus  becomes  sterile,  suppuration  ceases,  cough, 
fever  and  wasting  disappear,  the  patient  gains  weight,  and,  if  there 
is  no  necrotic  bone  present,  the  sinus  closes. 

The  paste  is  thought  by  Beck  to  act  by  chemotaxis.  Possibly 
it  acts  also  by  pressure,  and,  slightly  as  chemical  antiseptic.  Re- 
injection  is  practiced  only  when  the  paste  has  discharged  and  micro- 
organisms are  still  found  in  the  pus.  After  injection  a  pad  of  ster- 
ile gauze  is  applied  daily  until  the  sinus  closes.  If  fever  rises  to 
loi  F.  or  the  patient  complains  of  severe  pressure  the  accumulated 
fluid  should  be  drained  off,  and  the  sinus  be  allowed  again  to  close. 
Possible  symptoms  of  poisoning  may  appear.  These  are  cyanosis, 
blue  borders  on  the  gums,  albuminuria,  dyspnea,  diarrhoea,  loosen- 
ing of  the  teeth,  rapid  loss  of  weight,  death  unless  relieved.  A 
slight  blue  line  along  the  gums  only,  is  not  regarded  as  alarming  but 
should  be  closely  watched.  Poisoning  is  treated  first  by  removal  of 
the  paste  by  injecting  the  cavity  with  warm  sterile  olive  oil,  and 
withdrawing  the  resulting  emulsion  by  suction  pump  next  day. 
Large  quantities  of  water  should  be  ingested,  iodine  administered 
internally,  and  elimination  promoted.      (41  and  58.) 

CARDIOLYSIS  OR  PR.ffi:CARDIAL  THORACECTOMY 

This,  according  to  Berger  (Semaine  Medicale,  Sept.  7,  1910), 
is  practicable  in  adhesive  mediastinal  pericarditis  with  healthy  myo- 
cardium.     (58.) 

1  Instituted  by  Emil  G.  Beck,  1907.     Jour.  Am.  Med.  Assn.,  Mar.  14,  1908; 
Dec.  18,  1909.     A.  J.  Ochsner,  Ann.  Surg.,  July,  1909,  p.  151. 


CHAPTER  XX 

THE  ABDOMEN,  ITS  MALFORMATIONS  AND  DISEASES 

Its  Anatomy  in  Infancy  and  Childhood — Omphalitis — Ar- 
teritis AND  Phlebitis — Septic  Peritonitis — Umbilical 
Hemorrhage — Paralysis  of  Abdominal  Muscles — Acute 
Peritonitis  —  Appendicitis  —  Chronic  ( Non-tuberculous) 
Peritonitis — Tuberculous  Peritonitis. 

ITS  ANATOMY  IN  INFANCY  AND  CHILDHOOD 

In  the  infant  and  child  the  abdomen  normally  is  large  in  propor- 
tion to  the  whole  individual,  and  appears  more  so  because  of  the 
small  size  of  the  thorax  and  pelvis.  It  contains  not  only  the  organs 
found  in  the  adult,  but  the  bladder  and  upper  end  of  the  rectum. 
In  the  new-born  the  liver  is  very  large  in  proportion,  being  one- 
eighteenth  of  the  whole  body  weight.  In  the  adult  it  is  one-thirty- 
sixth.  If  a  line  be  drawn  from  a  little  below  the  lower  margin  of 
the  thorax  on  the  left  side  to  a  few  centimetres  above  the  crest  of 
the  ilium  on  the  right,  the  liver  will  be  found  to  occupy  the  space 
above  it,  which  is  nearly  one-half  the  abdomen.  In  the  other  half 
are  the  intestines,  the  stomach,  spleen,  upper  portion  of  rectum  and 
the  bladder.  (Ribemont.)  It  is  in  order  to  accommodate  this  large 
liver  and  the  bladder  and  rectum,  which  have  not  sufficient  room  in 
the  diminutive  pelvis,  that  the  abdomen  is  so  large.  The  large  in- 
testine occupies  somewhat  the  same  position  that  it  does  in  the  adult, 
but  the  cecum  is  apt  to  be  a  little  higher  and  not  uncommonly  pro- 
jects to  the  middle  line  or  even  to  the  left  of  it,  and  during  the  first 
two  years  of  life  may  not  have  taken  the  position  to  the  right  side 
of  the  abdomen.  The  colon  in  its  ascent  from  the  cecum  soon  comes 
in  contact  with  the  liver;  and  sometimes  instead  of  crossing  trans- 
versely to  the  splenic  flexure,  it  crosses  to  the  left  diagonally  down- 
ward. The  sigmoid,  with  its  long  meso-sigmoid,  instead  of  occu- 
pying its  usual  adult  position  in  the  left  hypogastrium,  may  lie  across 
in  the  supra-pubic  region  or  over  to  the  right  near  the  cecum,  or  it 
may  hang  down  into  the  pelvis,  and  give  rise  to  a  variety  of  partial 
fecal  impaction.  (Jacobi.)  The  abdominal  walls  themselves,  except- 
ing the  subcutaneous  fat,  are  very  thin.  In  the  region  of  the  kid- 
neys the  muscles  are  so  slight  as  to  offer  but  little  protection  to  those 
organs.     The  omentum,  which  in  the  adult  is  often  such  a  substan- 

52,2 


THE  ABDOMEN,  ITS   MALFORMATIONS   AND  DISEASES      533 

tial  apron  loaded  with  adipose  tissue,  in  the  infant,  as  Mr.  Owen 
says,  "  but  thinly  shadows  forth  its  future  greatness."  The  umbili- 
cus is  placed  relatively  low.  In  the  new-born  it  is  at  the  central 
point  or  one  to  two  centimetres  below  the  central  point,  of  the  whole 
figure.  It  is  low  also  with  relation  to  the  vertebrae.  In  the  adult 
the  umbilicus  corresponds  to  the  lower  border  of  the  third  or  upper 
border  of  the  fourth  lumbar  vertebrae.  In  the  infant  it  is  level  with 
the  disc  between  the  fourth  and  fifth  lumbar  vertebrae  (Ballantyne), 
being  therefore  fully  one  vertebra  lower,  and  but  a  little  above  the 
level  of  the  iliac  crests.  With  growth  of  the  pelvis,  lower  abdomen, 
and  of  the  lower  extremities,  the  umbilicus  becomes  relatively  higher 
up  on  the  abdomen  and  the  os  pubis  becomes  the  central  point  of  the 
whole  figure.  Other  anatomical  peculiarities  in  the  young  subject 
will  be  pointed  out  in  discussing  the  diseases  of  special  organs. 

Examination  of  the  Abdomen. — The  examination  of  the  abdo- 
men in  infants  and  children  is  often  extremely  difficult.  Through 
fear  or  restlessness  or  nervousness  the  position  so  constantly  changes 
or  the  muscles  are  rendered  tense  that  in  some  instances  it  may  be 
impossible  to  make  satisfactory  examination  without  sleep,  either 
natural  or  induced  by  an  anesthetic.  The  abdomen  may  be  found 
distended  by  gases,  and  this  may  be  uniform,  or  confined  to  a  certain 
portion  if  obstructed  bowel  prevents  its  distribution  throughout  the 
entire  canal.  Fluid  free  in  the  peritoneal  cavity  will  cause  uniform 
distension  ;  but  an  enlarged  viscus  or  a  tumor  will  produce  a  localized 
swelling.  Enlarged  veins  upon  the  surface  of  the  abdomen  are  found 
with  any  enlargement  which  impedes  the  return  circulation,  whether 
this  is  due  to  chronic  peritonitis  with  efifusion,  or  tumor,  malignant 
or  innocent.  The  abdominal  walls  may  be  flattened  or  depressed, 
especially  in  acute  brain  or  meningeal  disease ;  or  relaxed  in  collapse 
or  early  in  intussusception.  They  may  be  so  extremely  wasted  and 
transparent  that  the  coils  of  the  intestines  and  peristalsis  may  be 
readily  observed  by  sight ;  and  in  cases  of  pyloric  stenosis  the  re- 
verse peristalic  wave  of  the  stomach  may  be  seen. 

Palpation  of  the  abdomen  by  a  warm  and  gentle  hand  is  exceed- 
ingly valuable,  but  more  difficult  than  inspection.  The  thin  walls 
of  the  child's  abdomen  would  offer  but  a  slight  barrier  to  the  sense 
of  touch  if  these  were  only  relaxed  and  unresisting.  If  this  condi- 
tion can  be  secured  by  sleep  or  by  distraction  of  the  attention  much 
valuable  information  may  be  obtained.  The  tumor  of  intussuscep- 
tion or  of  a  new  growth  or  of  enlarged  liver  or  spleen,  or  mesen- 
teric glands,  or  fecal  impaction,  or  distended  bladder,  or  enlarged  or 
displaced  kidneys,  or  an  abscess,  or  a  sacculated  ascites,  may  be  pal- 
pated ;  and  wave  impulses  sent  through  a  collection  of  fluid.  The 
most  difficult  points  to  establish  are  those  we  are  often  very  anxious 
to  ascertain,  namely,  whether  there  is  muscular  rigidity,  and  whether 


534  SURGICAL   DISEASES    OF    CHILDREN 

there  is  pain  or  tenderness.     Much  tact,  patience,  and  experience 
will  all  be  necessary  to  success  in  this  part  of  the  examination. 

Percussion  will  enable  the  examiner  to  determine  whether  an 
enlargement  is  gaseous  or  of  more  solid  consistency.  But  it  should 
be  remembered  the  tension  may  be  so  great  in  gaseous  distension 
that  the  percussion  note  almost  simulates  dullness ;  and  that  the 
proximity  of  a  viscus  distended  with  gas  will  often  give  a  tympanitic 
note  when  percussing  a  solid  body.  A  much  lighter  tap  of  the  finger 
than  would  be  necessary  in  the  adult  gives  a  truer  note. 

Malformation  at  the  Linea  Alba  and  the  Umbilicus. — Some- 
times there  is  a  failure  of  the  ventral  laminae  to  meet  in  the  middle 
line,  thus  causing  a  hiatus  of  the  abdominal  wall.  If  this  occurs  in 
the  region  of  the  bladder  the  anterior  wall  of  that  viscus  may  be  lack- 
ing— extroversion  of  the  bladder,  (q.  z:).  In  less  severe  deformity, 
where  only  the  recti  muscles  fail  to  meet,  a  ventral  hernia  may  result. 
The  protrusion  may  be  a  portion  of  the  liver — hepatomphalos — or 
intestines  or  stomach.  The  condition  is  to  be  treated  by  the  appli- 
cation of  pad  and  binder  or  by  operation  bringing  the  muscular 
margins  of  the  opening  together  and  uniting  them  by  suture. 

The  umbilical  cord  may  retain  its  fetal  condition,  containing  a 
coil  of  intestine  or  other  organ  enclosed  in  a  more  or  less  distended 
sac  outside  the  plane  of  the  abdominal  wall — exomphalos.  The  cord 
may  be  so  thin  and  transparent  that  its  contents  can  be  plainly  dis- 
cerned, or  it  may  be  so  normal  in  external  appearance  and  so  little 
distended  that  a  loop  of  intestine  might  be  ligated  within  it  and  cut 
without  suspicion  on  the  part  of  the  accoucheur.  Or  the  structures 
of  the  cord  may  appear  as  though  spread  out  to  form  a  portion  of 
the  abdominal  wall  left  incomplete  by  failure  of  the  ventral  laminse 
to  meet  in  the  middle  line,  and  on  sloughing  away  leave  the  abdomi- 
nal wall  deficient.  Closure  by  approximation  of  the  margins  and 
suture  is  indicated,  and  may  succeed,  but  often  fails.  These  deform- 
ities are  analogous  to  hare-lip  and  cleft-palate,  spina  bifida,  epispa- 
dias and  hypospadias,  and  some  forms  of  meningocele. 

■  jMeckel's  diverticulum  may  open  at  the  umbilicus,  thus  produc- 
ing a  fecal  fistula.  Wright  ligated  the  protrusion  and  strapped  the 
opening,  procuring  a  closure.  Owen  advised  emptying  the  bowel 
thoroughly  by  purgation  and  the  subsequent  use  of  opium  to  induce 
rest  of  the  parts ;  in  the  meantime  applying  a  dry  pad  and  leaving  it 
undisturbed.  Wright  thinks  this  treatment  applicable  rather  to  older 
children  than  to  infants.  For  umbilical  hernia,  see  Chapter  on  Her- 
nia, and  for  patent  urachus  see  the  Chapter  on  Genito-urinary 
Organs. 

OMPHALITIS 

Infection  by  septic  organisms  may  give  rise  to  inflammation  of 
the  umbilicus  and  of  the  abdominal  wall  surrounding  it.     It  usually 


The  abdomen,  its  malformations  and  diseases    535 

occurs  in  the  first  few  w.eeks  of  life,  often  the  second  or  third  week, 
beginning  before  the  umbiUcus  has  healed,  although  it  may  appar- 
ently have  done  so.  The  cause  may  be  any  of  the  common  pyogenic 
bacteria,  either  staphylococci  or  streptococci,  or  more  rarely  the 
gonococcus  or  pneumococcus.  According  to  the  virulence  of 
the  inflammation  and  the  resistance  of  the  tissues  the  disease  remains 
local  and  superficial  or  it  may  involve  the  whole  thickness  of  the 
abdominal  wall  and  extend  over  a  large  area,  or  attack  the  umbilical 
vessels  or  the  peritoneum ;  and  may  terminate  in  resolution  in  ab- 
scess or  in  gangrene. 

Sy)iipfo}n>s. — The  symptoms  are  redness,  swelling  and  infil- 
tration ;  and  sometimes  ulceration,  bleb  formation  and  sloughing, 
with  constitutional  symptoms  of  septicemia. 

Treatment. —  (See  Sections  on  Septic  Peritonitis,  Cellulitis,  Sep- 
ticemia.) 

ARTERITIS   AND    PHLEBITIS 

Infection  conveyed  by  the  lymphatics  and  involving  the  con- 
nective tissues  may  attack  the  blood  vessels.  Contrary  to  the  pre- 
vailing belief,  Runge  considers  arteritis  very  much  more  common 
than  phlebitis,  the  vein  being  alone  diseased  in  only  about  one- 
half  of  one  per  cent,  of  the  whole  number  of  cases.  The  disease  of 
the  vessels  may  follow  omphalitis  or  there  may  be  no  external  evi- 
dence of  inflammation.  The  arteries  as  far  as  the  bladder  may  be 
afifected,  becoming  thrombotic,  and  containing  pus,  which  sometimes 
oozes  out  at  the  umbilicus.  Other  septic  foci  also  develop,  in  cellu- 
lar tissues,  joints,  bones,  periosteum,  kidneys,  spleen,  the  parotid 
glands,  the  meninges,  or,  most  commonly,  the  lungs.  Phlebitis  may 
extend  to  the  liver  and  give  rise  to  hepatitis  with  multiple  abscesses, 
and  jaundice. 

SEPTIC    PERITONITIS 

This  usually  originates  in  omphalitis,  or  in  arteritis.  It  may 
extend  generally  over  the  abdomen  or  remain  localized  near  the 
umbilicus  or  the  liver.  There  is  free  exudation  of  plastic  lymph  with 
formation  of  adhesions,  sometimes  with  abscesses  pocketed  among 
the  adhesions. 

Symptoms. — The  symptoms  are  dorsal  decubitus,  rigid  abdom- 
inal muscles,  flexion  of  the  thighs  upon  the  abdomen,  and  thoracic 
breathing.  General  symptoms  of  sepsis  accompany  these  infec- 
tious inflammations.  (See  Sections  on  Septicemia,  on  Erysipelas 
and  on  Cellulitis.) 

Treatment. — The  treatment  of  omphalitis  or  of  any  of  its  com- 
plications that  can  be  exposed,  is  the  same  as  the  treatment  of 
pyogenic  inflammation  elsewhere:  thorough  cleanliness;  the  use  of 
antiseptic  washes  or  wet  compresses,  with  solution  of  salicylic 
acid    (Runge),  boric  acid,  mercuric  bichloride  and  the  like,  of  a 


536  SURGICAL   DISEASES    OF   CHILDREN 

strength  to  meet  the  virulence  of  the  infection  and  the  stage  of  the 
inflammatory  process.  All  accessible  abscesses  are  to  be  evacu- 
ated and  washed  out  and  drained.  Treatment  of  erysipelas  and 
septic  cellulitis  will  be  found  in  appropriate  sections.  In  pyemic 
abscesses  of  brain,  liver,  lung  and  peritoneum  little  can  be  done. 
All  cases  suffering  with  septic  diseases  need  the  best  of  nourish- 
ment and  often  the  free  use  of  stimulants. 

UMBILICAL  HEMORRHAGE 

Hemorrhage  may  follow  imperfect  ligature  of  the  cord  or  cut- 
ting of  the  cord  by  a  thin  ligature ;  or  by  slipping  of  the  ligature ; 
or  by  its  becoming  loose  by  shrinking  of  the  cord  after  it  is  cut.  A 
cord  will  not  invariably  bleed  even  if  left  untied.  But  bleeding  occurs 
under  certain  conditions  of  asphyxia  and  of  imperfect  muscular  ac- 
tion and  in  certain  states  of  the  blood.  It  may  occur  idiopathically 
or  spontaneously  as  a  symptom  of  hemophilia,  or  of  syphilis  or  of 
hemorrhagic  disease  or  of  fatty  degeneration  of  the  new-born.  In 
these  children  the  coagulation  time  of  the  blood  is  slow ;  and  it 
seems  almost  impossible  in  some  instances  to  stop  the  flow.  It 
is  this  form  which,  while  more  rare,  is  also  more  dangerous.  It  is 
apt  to  begin  a  few  days  after  birth,  either  just  before  or  just 
after  the  separation  of  the  cord — very  often  about  the  fifth  day. 
It  may  be  accompanied  by  hemorrhage  from  stomach  or  bowels, 
or  purpuric  spots  beneath  the  skin,  or  edema  of  extremities ;  or  it 
may  be  the  only  manifestation  of  the  hemorrhagic  tendency.  The 
child  may  have  appeared  quite  healthy  and  doing  well  up  to  the  be- 
ginning of  the  hemorrhage;  or  an  apparently  healthy  baby  may 
show  some  drowsiness,  perhaps  vomiting,  cyanosis,  or  icterus  or 
other  disturbance  before  the  bleeding  begins.  The  hemorrhage 
takes  place  as  a  general  oozing  from  the  umbilical  site  or  around  the 
stump  of  the  cord.  Xo  individual  vessel  can  be  seen  either  spurting 
or  flowing.  The  peculiarity  of  the  hemorrhage  is  its  persistence. 
A  fair  example  of  such  a  case  is  one  seen  by  me  in  consultation  with 
Dr.  Robert  Bailey.  On  the  first  day  of  the  babe's  life  a  slight  pin 
scratch  on  the  babe's  leg  bled  forty-eight  hours.  On  the  third  day 
the  umbilicus  bled  persistently.  The  cord  was  not  yet  detached,  but 
at  its  point  of  attachment  blood  oozed  continuously.  Dr.  Bailey  had 
tried  collodion  covered  by  adhesive  plaster,  tannic  acid,  ^Monsell's 
solution,  lead  acetate,  sulphate  of  copper,  and  other  astringents. 
The  extract  of  the  adrenals  was  then  unknown  and  calcium  chloride 
not  used.  But  the  oozing  continued.  I  finally  transfixed  the  cord 
with  two  needles  at  a  distance  of  an  inch  or  more  from  the  belly 
wall,  and  then  wound  the  cord  beneath  the  needles  as  if  it  were  a 
spool,  with  woollen  yarn.  This  stopped  the  bleeding.  Albuminate 
of  iron  was  prescribed.    The  baby  recovered.    In  this  case  the  cause 


THE  ABDOMEN,  ITS  MALFORMATIONS  AND  DISEASES      S37 

was  probably  hemophilia.  The  same  mother  had  lost  one  infant  of 
umbilical  hemorrhage,  and  other  infants  had  been  lost  from  the 
same  cause  by  her  mother  and  other  relatives.  Among  the  reme- 
dies recommended  are  the  actual  cautery,  galvano  cautery,  under- 
pinning and  ligaturing,  adrenalin  chloride  locally  and  internally  and 
calcium  chloride  internally.     (See  also  Hemophilia.) 

Umbilical  Polypus  is  described  in  the  Chapter  on  Tumors. 

PARALYSIS  OF  ABDOMINAL  MUSCLES 

This  may  follow  poliomyelitis  anterior  acuta  and  may  be  very 
puzzling  unless  its  possibility  be  borne  in  mind. 

ACUTE  PERITONITIS 

Acute  peritonitis  does  not  so  very  often  come  under  the  notice 
of  the  children's  surgeon ;  yet  whenever  it  does  so  it  presents  inter- 
esting and  important  conditions.  No  child  is  too  young  to  have 
peritonitis,  either  acute  or  chronic.  It  may  occur  in  the  fetus ;  not. 
as  was  formerly  supposed,  always  because  of  syphilis,  but  from 
the  poisons  of  the  exanthemata  circulating  in  the  mother's  blood, 
or  septic  causes,  or  possibly  trauma,  or  inexplicable  causes.  Doubt- 
less fetal  peritonitis  accounts  for  some  of  the  cases  of  malforma- 
tions of  abdominal  viscera,  and  of  adhesions  between  them,  which 
occasionally  give  rise  to  serious  symptoms  later. 

Acute  peritonitis  of  the  new-born  has  been  alluded  to  in  con- 
nection with  inflammations  of  the  umbilicus.  After  this  period  it  is 
quite  rare  throughout  infancy,  but  becomes  more  prevalent  in  child- 
hood and  youth.  It  is  primary,  or  more  often  secondary.  It  may  be 
due  to  accidental  traumatism,  blows,  falls  or  burns,  or  to  surgical 
traumatism,  or  possibly  to  exposure.  When  secondary  it  may  arise 
in  mechanical  causes  such  as  malformations,  intussusception, 
strangulation  of  intestines,  volvulus,  or  foreign  bodies,  or  from 
extension  of  inflammation  in  adjacent  structures,  such  as  inflam- 
mation of  the  abdominal  parietes,  pleurisy,  perinephric  abscess, 
spinal  caries,  caries  of  pelvic  bones.  Or  peritonitis  may  occur  in  the 
course  of  or  following  scarlet  fever,  influenza  or  penumonia,  or 
other  infectious  disease.  Or  it  may  come  from  disease  arising  in 
the  gastro-intestinal  tract  or  its  appendages.  From  this  source 
appendicitis  is  a  representative  and  one  of  the  most  frequent  causes 
of  peritonitis  in  the  whole  list.  Perforation  or  extension  from 
typhoid  ulcer  or  other  ulceration  of  the  intestine,  or  from  gastric 
ulcer  is  extremely  rare  in  children. 

Infections  from  the  genito-urinary  tract  are  comparatively  rare, 
in  marked  contrast  to  the  frequent  uterine  and  tubal  implications 
of  the  peritoneum  in  the  adult.     But  gonorrheal  vulvo-vaginitis  in 


53^  SURGICAL   DISEASES    OF    CHILDREN 

girls  may  originate  peritonitis.  The  microbic  cause  of  peritonitis  is 
most  often  the  streptococcus  in  the  septic  infections  of  the  new- 
born, the  pneumococcus,  and  the  bacterium  coli  communis. 

Pathology. — The  inflammation  may  be  locaHzed  or  general.  In 
children  there  is  a  strong  tendency  for  it  to  become  general.  It  may 
present  one  of  three  forms :  fibrinous,  serous,  or  purulent ;  or  accord- 
ing to  the  infection  or  re-infection  it  may  merge  from  one  of  the 
slighter  to  a  more  severe  type.  In  children  the  tendency  is  to  be- 
come purulent.  In  the  fibrinous  form  there  is  vascular  injection 
and  escape  of  plasma  and  corpuscles.  The  lining  endothelium  of 
the  membrane  becomes  swollen  and  its  cells  desquamate.  There  is 
exudation  of  a  small  quantity  of  serous  fluid  and  a  larger  amount  of 
plastic  lymph,  most  abundant  where  coils  of  intestine  are  in  contact. 
Here  the  membrane  is  most  reddened  and  swollen  and  covered  with 
the  yellowish-white  fibrinous  exudation.  Adhesions  are  produced 
between  any  adjacent  serous  surfaces.  These  adhesions,  soft  and 
yielding  at  first,  become  tenacious  after  a  time. 

In  the  serous  form  the  inflammation  induces  a  free  outpouring 
of  serum,  the  lymph  being  in  comparatively  small  quantity.  The 
serous  exudate  frequently  undergoes  absorption.  If  adhesions  occur 
in  this  form  they  are  not  as  extensive. 

In  the  purulent  form  the  exudate  may  be  only  fibro-plastic  or 
serous  at  first,  and  then  rapidly  become  purulent ;  or  it  may  become 
purulent  from  the  beginning,  depending  on  the  nature  and  virulence 
of  the  infection.  If  the  inflammation  begin  locally  and  fibro-plastic 
adhesions  have  taken  place  before  pus  formation,  the  result  may 
be  a  localized  peritoneal  abscess.  Or  with  rapid  extension  of  the 
purulent  inflammation  the  pus  may  be  free  in  the  peritoneal  cavit}-. 
Or  it  may  be  contained  in  numerous  pockets  formed  by  adhesions 
between  coils  of  intestines  or  other  viscera.  If  the  patient  survives, 
such  abscesses  may  discharge  externally,  either  through  the  abdom- 
inal wall  or  by  burrowing  to  the  surface  at  a  distance  or  by  burst- 
ing into  any  of  the  hollow  viscera.  It  is  said  the  non-tubercular 
peritoneal  abscess,  the  pneumococcic  variety  especially,  tends  to 
discharge  at  the  umbilicus. 

Symptoms  mid  Diagnosis. — Sudden  onset  is  the  rule,  with  high 
fever,  vomiting  and  pain.  In  some  cases  there  is  little  fever.  The 
patient  prefers  the  dorsal  decubitus  with  the  thighs  flexed.  The 
abdomen  soon  becomes  swollen,  tympanitic,  tender,  with  its  muscles 
rigid.  The  respiratory  movements  of  the  diaphragm  are  restricted. 
The  tongue  is  dry  and  red.  Thirst  is  tormenting,  but  drink  not 
retained.  Pulse  rapid  and  small  and  at  first  hard,  later  thready.  Con- 
stipation is  the  rule,  to  which  there  are  exceptions.  The  mind 
remains  clear.  Death  occurs  in  the  majority  of  cases,  often  with 
the  Hippocratic   face,  a  wet  skin,  a  running  pulse  and  collapse. 


THE  ABDOMEN,  ITS   MALFORMATIONS   AND  DISEASES      539 

Infants  may  succumb  on  the  third  or  fourth  day.  Older  children 
survive  a  week  or  ten  days.  In  some  cases,  hectic  fever,  chills  and 
sw^eats  indicate  pus  formation.  Perhaps  dullness  and  fluctuation  can 
be  made  out  at  some  location.  The  navel  may  protrude,  become  red, 
soften  and  open,  discharging  a  quantity  of  pus ;  or  the  abscess  may 
point  in  the  hypogastrium  or  in  the  loin.  The  pus  varies  in  character 
and  consistency.  In  the  pneumococcus  infection  it  is  apt  to  be 
creamy,  greenish  and  ready  to  clot.  With  the  bacillus  coli  there  is 
a  vile  odor. 

If  peritonitis  sets  in  after  an  abdominal  operation,  the  pain 
which  was  present  before,  instead  of  disappearing  or  at  least  sub- 
siding, grows  worse.  Vomiting,  if  absent  before,  now  appears ;  or 
if  present  before  persists  and  becomes  more  troublesome.  The 
abdomen  becomes  tympanitic  and  tender.  The  face  looks  anxious 
and  distressed.  The  patient  prefers  the  dorsal  decubitis  and  flexes 
his  thighs  as  before-  described.  Temperature  and  pulse  may  run 
up ;  but  of  still  graver  import  is  a  falling  temperature  with  a  rising 
pulse. 

Prognosis. — The  prognosis  is  very  serious  indeed  in  all  cases. 
Yet  they  vary  somewhat  according  to  cause,  extent  and  location. 
The  septic  infections,  especially  those  of  the  new-born,  are  usually 
fatal.  In  older  children,  as  a  rule,  there  is  some  hope.  If  the  in- 
flammation is  localized  the  outlook  is  not  so  bad,  even  if  suppuration 
ensue.  In  the  fibrinous  form  there  is  hope  even  if  the  inflammation 
is  general. 

Treatment. — Treatment  depends  on  the  cause,  and  the  stage 
of  the  inflammation.  Opium  is  a  drug  which  has  in  the  past  been 
almost  invariably  resorted  to  in  peritonitis  on  account  of  the  pain, 
which  is  often  severe.  If  the  pain  is  not  beyond  endurance  opium 
should  be  withheld  or  very  sparingly  used,  at  least  until  the  bowels 
are  thoroughly  emptied.  P'or  this  purpose  salines,  citrate  or  sulphate 
of  magnesia  are  the  best  if  the  stomach  will  tolerate  them.  The 
saline  should  be  given  in  broken  doses  and  well  diluted.  It  is  often 
well  to  give  a  few  doses  of  calomel  before  the  saline ;  and  if  the 
stomach  rejects  the  saline  the  purgation  is  secured  by  calomel. 
After  the  bowels  are  thoroughly  emptied  it  is  not  well  to  continue 
active  purgation  for  any  length  of  time  for  the  sake  of  depletion. 
Rest  is  at  that  time  of  more  value,  and  affords  nature  an  opportunity 
to  "  wall  off  "  the  inflammatory  focus.  Copious  irrigation  of  the 
bowels  with  normal  saline  solution  at  this  time  aids  in  emptying  them. 
Later,  if  vomiting  persists,  saline  injections  are  used  to  relieve 
thirst  and  furnish  water  to  the  circulation  for  purposes  of  the  elim- 
ination of  toxines  by  the  natural  emunctories.  As  much  normal- 
saline  should  be  supplied  to  the  bowels  all  through  the  illness  after 
the  early  cleansing  as  they  will  absorb.    As  an  external  application 


540  SURGICAL   DISEASES    OF   CHILDREN 

cold  is  of  the  greatest  value.  Children  will  object  to  the  icebag  if  it 
is  applied  too  near  the  skin,  but  usually  not  if  a  layer  or  a  few 
layers  of  flannel  are  placed  between  the  icebag  and  the  skin.  Young 
children  are  very  easily  affected  by  cold,  and  can  be  seriously  de- 
pressed by  it.  The  ice  should  be  broken  small  and  the  icebag  made 
comfortably  flat,  and  only  comfortably  cold.  Pain  and  tenderness 
can  be  greatly  relieved  by  smearing  the  abdomen  with  ext.  bellad. 
5i  to  glycerine  §i,  under  oil  silk. 

Heat  also  relieves  pain,  but  it  does  not  check  the  acute  inflam- 
matory process.  It  should  be  used  in  the  depressed  cases  with  low 
temperature. 

The  tympanites  can  be  relieved  by  turpentine  stupes  or  by  in- 
jections of  milk  of  asafetida  in  water.  If  the  invasion  of  the  peri- 
toneum results  in  suppuration,  or  is  caused  by  intestinal  perforation 
or  the  bursting  of  an  abscess  into  the  cavity,  laparotomy  is  indicated. 
The  perforation  must  be  repaired  or  the  abscess  emptied  and  washed 
out,  and  the  abdominal  cavity  thoroughly  flushed  with  hot  normal 
salt  solution,  drainage  introduced  into  its  lowest  portion  and  the 
incision  closed,  to  the  drainage.  The  head  of  the  bed  should  be 
raised,  placing  the  patient  in  "  Fowler's  position,"  since  the  lower 
portion  of  the  peritoneum  is  less  active  in  the  absorption  of  toxines 
than  that  nearer  the  diaphragm.  If  the  stomach  becomes  quiet, 
stimulants,  and  food  in  the  form  of  broths  and  peptones,  can  be 
swallowed.    Otherwise  they  must  be  given  per  rectum.  (42) 

APPENDICITIS 

Few  diseases  have  been  more  fully  discussed  in  recent  years 
than  this  one.  Its  prevalence,  causation,  pathology,  symptomatology, 
diagnosis  and  treatment,  especially  operative  treatment,  have  each 
been  considered  in  every  phase.  At  the  present  time,  although  opin- 
ion is  not  quite  unanimous  upon  every  minor  point,  all  are  agreed 
that  our  knowledge  of  the  disease  and  success  in  handling  it  have 
advanced  remarkably,  and  upon  the  main  features  of  the  subject 
there  can  be  no  question.  The  disease  many  of  us  as  medical  stu- 
dents were  taught  as  typhilitis  and  perityphlitis,  and  treated  medi- 
cally up  to  the  stage  of  a  pointing  abscess,  is  now  considered  under 
the  heading  of  appendicitis  and  is  regarded  as  a  surgical  disease  from 
the  time  the  diagnosis  can  be  made.  Whether  there  is  such  a  disease 
as  perityphlitis  occurring  independently  of  the  vermiform  appendix 
is  doubtful.  It  seems  possible,  considering  the  anatomy  of  the 
cecum  and  its  liability  to  impaction ;  yet  it  is  now  known  to  be  very 
rare,  if  it  ever  occurs,  as  compared  with  inflammation  of  the  ap- 
pendix. 

Etiology. — The  earlier  theory  that  appendicitis  is  frequently 
caused  by  a  foreign  body  has  been  abandoned,  although  no  one 
doubts  that  foreign  bodies  are  occasionally  found  in  the  appendix. 


THE   ABDOMEN,  ITS   MALFORMATIONS   AND  DISEASES      541 

Quite  frequently  fecal  concretions  are  found  molded  into  the  shape 
of  fruit  seeds  or  the  like,  and  these  may  formerly  have  been  regarded 
as  foreign  bodies.  Their  relation,  if  they  have  any,  to  appendical 
inflammation  is  uncertain.  It  seems  probable  that  they  may  prove 
a  source  of  irritation,  or  interfere  with  the  circulation  and  cause 
pressure  necrosis,  or  delay  the  expulsion  of  mucus  and  so  form  a 
nidus  for  bacteria.  But  some  regard  them  rather  as  an  effect  of  a 
low  grade  of  inflammation,  the  mucus  which  results  being  mixed 
with  fecal  matter  and  forming  the  concretions. 

As  Morris  Richardson  remarks,  "  The  worst  thing  that  can  get 
into  the  appendix  is  a  bacterium."  Many  varieties  of  bacteria  have 
been  found  associated  with  this  disease,  among  which  may  be  men- 
tioned the  bacillus  coli  communis,  the  staphylococcus  pyogenes  au- 
reus, the  streptococcus  pyogenes,  the  proteus  vulgaris,  and  the 
pneumococcus.  The  most  common  and  the  most  active  are  the  strep- 
tococci and  the  bacillus  coli.  The  reasons  why  these  organisms  so 
frequently  are  able  to  attack  the  appendix  are  thought  to  be:  Be- 
cause it  is  a  vestigeal  organ  undergoing  a  retrograde  metamorphosis, 
and  therefore  its  vitality  is  low ;  because  of  the  anatomical  peculiari- 
ties of  the  structure,  shape  and  position  of  the  appendix  .itself  and 
of  the  mesentery ;  and  of  its  imperfect  drainage.  Age,  sex,  food  and 
condition  of  the  digestive  organs  have  some  influence  as  well  as  the 
effects  of  typhoid  fever.  Holt  considers  appendicitis  exceedingly 
rare  in  infancy,  having  never  once  been  found  in  about  2000  autop- 
sies, nearly  all  upon  children  under  two  years  of  age,  in  three  insti- 
tutions with  which  he  was  connected.  But  he  has  seen  it  once  at 
nine  and  once  at  fourteen  months ;  and  quotes  a  case  of  Goyens  in 
an  infant  only  six  weeks  old,  one  of  Shaw's  and  one  of  Demme's 
each  at  seven  weeks,  and  Savage's  at  nine  weeks  old.  D'Arcy  Power 
quotes  a  case  by  Tordeus  of  perforation  of  the  appendix,  with  a 
fatal  result,  in  a  babe  of  six  months ;  and  a  similar  case  by  Balzar  in 
a  babe  of  seven  months.  Deaver  states  that  15  per  cent,  of  all  cases 
occur  under  the  fifteenth  year,  of  which  but  few  are  under  the  fifth 
year.  Whether  this  is  because  time  is  necessary  for  the  formation 
of  coproHths,  which  are,  after  all,  predisposing  causes,  or  how  much 
change  of  diet  and  digestive  disturbances  of  long  standing,  expo- 
sure, trauma,  the  lowering  effects  of  various  exanthemata,  and  the 
overgrowth  of  connective  tissue,  worms,  oxyuris  and  lumbricoid, 
have  to  do  as  predisposing  causes  are  still  subjects  of  study. 

The  greater  liability  of  the  male  sex  to  appendicitis  is  as  con- 
spicuous in  childhood  as  in  later  life,  the  proportion  of  boys  to  girls 
being  two  to  one  (Manly).  This  is  at  least  partly  accounted  for 
by  the  better  circulation  through  the  appendiculo-ovarian  ligament. 

The  different  types  of  cecum  and  of  appendix,  and  the  varia- 
tions in  the  location  of  the  former  and  the  position  and  direction 
of  the  latter  as  they  are  found  in  the  adult  are  all  explained  in  works 


542  SURGICAL   DISEASES    OF    CHILDREN 

on  general  surgery.  All  these  are  found  with  equal  frequency  in 
the  child,  which  has,  besides,  peculiarities  of  its  own.  That  type  of 
adult  cecum  and  appendix  in  which  the  cecum  tapers  to  a  funnel 
or  conical  shape  as  it  merges  into  the  appendix,  known  as  the  fetal 
type,  is  more  apt  to  be  met  in  the  very  young.  While  this  shape 
would  apparently  favor  the  passage  of  material  from  cecum  into 
appendix,  the  absence  of  constriction  at  the  junction  of  cecum  and 
appendix  also  favors  emptying  of  the  latter.  The  appendix  is  de- 
veloped early  in  the  embryo,  while  the  intestines  have  not  reached 
their  full  development  at  birth.  They  continue  the  process  rapidly 
for  a  time  after  birth,  the  appendix  not  continuing  to  develop  but 
changing  its  position  and  shape  according  to  the  transitional  migra- 
tion of  the  cecum  and  the  control  of  the  meso-appendix.  When 
compared  with  the  appendix  of  the  adult,  that  of  the  infant  is  larger 
in  proportion  to  the  body,  and  is  considerably  larger  in  proportion 
to  the  size  of  the  entire  alimentary  canal.  The  coats  of  the  appendix, 
especially  the  sub-mucous  coat,  are  more  delicate  in  the  young  sub- 
ject. (H.  A.  Kelly.)  In  many  children  the  meso-appendix  is  very 
short,  leaving  that  portion  of  the  appendix  which  extends  beyond  it 
deficient  in  vascular  supply.  The  primitive  position  of  the  cecum  in 
the  embryo  is  in  the  left  of  the  middle  line  near  the  height  of  the 
umbilicus,  from  which  position  with  development  and  growth  it  ro- 
tates, moves  to  the  right  and  descends.  A  part  of  this  relative 
change  of  position  is  due  to  the  ascent  of  the  umbilicus.  (See  the 
beginning  of  this  chapter.)  In  many  young  subjects  the  location  of 
the  cecum,  and  with  it  the  appendix,  varies  considerably  from  the 
adult  type,  where  we  look  for  it  in  the  neighborhood  of  "  AIcBur- 
ney's  point,"  that  is,  on  a  Hne  between  the  anterior  superior  spine  of 
the  right  ilium  and  the  umbilicus,  at  the  outer  border  of  the  rectus 
muscle.  Instead,  it  is  often  higher  and  farther  toward  the  middle 
line,  or  even  projecting  beyond  it,  having  not  completed  the  usual 
change  of  position  to  the  right  and  downward.  (Young,  D wight, 
Ballantyne.)  Or  in  unusual  instances,  as  in  one  of  my  cases,  the 
cecum  and  appendix  may  be  found  in  an  inguinal  or  scrotal  hernia ; 
or  it  may  be  up  under  the  liver  or  near  the  spleen  or  kidney.  The 
omentum  in  the  young  subject  is  both  small  and  filmy  and  affords 
but  a  slight  barrier  between  the  general  peritoneal  cavity  and  a  dis- 
eased appendix. 

Pathology. — Appendicitis  may  be  described  as  acute,  and 
chronic  or  recurrent;  and  as  catarrhal,  suppurative  or  gangrenous. 
Ulceration  and  local  perforation,  which  are  sometimes  classified  as 
separate  forms  of  the  disease,  are  as  well  described  as  sub-varieties 
of  the  suppurative  and  gangrenous  forms. 

Catarrhal  Appendicitis  is  an  inflammation  of  the  mucous 
membrane  of  the  appendix  with  swelling  of  its  follicles  and  round 


THE   ABDOMEN,  ITS   MALFORMATIONS   AND  DISEASES      543 

cell  infiltration.  This  leads  to  pouring  out  of  mucus  or  muco-pus 
which  distends  the  appendix.  The  follicular  inflammation  may  re- 
sult in  ulcers  which,  however,  do  not  extend  deeper  than  the  mucosa. 
The  inflammation  and  infiltration  may  penetrate  to  the  muscular  and 
even  to  the  serous  coats,  and  the  organ  become  swollen  to  many 
times  its  natural  size,  stififened  and  edematous.  This  may  entirely 
subside  and  complete  recovery  follow;  or  more  likely  there  will  re- 
main some  changes,  such  as  partial  or  even  complete  closure  of  the 
lumen  by  cicatricial  constriction ;  or  adhesions  to  surrounding  struct- 
ures; or  the  inflammation  may  progress  and  merge  into  the  sup- 
purative form ;  or  after  subsiding  for  the  time  being,  be  followed  by 
a  chronic  inflammation  or  by  recurrent  attacks. 

Suppurative  Appendicitis  may  begin  as  a  primary,  acute 
catarrhal  inflammation,  or  it  may  come  as  a  recurrence  after  a  catar- 
rhal attack;  or  it  may  be  suppurative  from  the  start.  The  mucous 
membrane  and  sub-mucosa,  the  muscular  and  the  serous  coats 
are  extensively  involved  and  the  serous  much  more  apt  to  be  than 
with  the  catarrhal  form.  The  rapidity  of  the  inflammation  and 
character  of  the  pus  formed  varies  with  the  infecting  agent,  but  there 
is  an  accumulation  of  pus  in  the  appendix  with  swelling  and  dis- 
tension of  the  organ.  This  form  may  terminate  in  escape  of  the  pus 
into  the  cecum,  and  subsidence  of  the  inflammation,  leaving  consid- 
erable fibrosis  of  the  walls  of  the  tube  and  adhesions  of  the  serous 
coat  to  adjacent  structures.  This  fortunate  course  is  not  the  usual 
one.  It  is  more  usual  to  have  the  collection  of  pus  burst  through 
the  coats  of  the  appendix  either  by  a  process  of  pressure  necrosis  or 
of  ulceration.  The  subsequent  history  will  depend  upon  circum- 
stances. If  inflammatory  adhesions  had  formed  which  retain  the 
pus,  it  constitutes  a  circumscribed  peritoneal  abscess,  localized  ac- 
cording to  the  location  of  the  appendix  and  point  of  perforation. 
In  children  there  is  less  tendency  to  the  formation  of  protective 
adhesions  than  in  adults;  and  the  adhesions  are  more  delicate  and 
easily  torn.  Such  an  abscess  may  be  post-cecal,  between  the  lay- 
ers of  the  ascending  meso-colon,  or  immediately  beneath  the  anterior 
parietal  peritoneum  confined  by  adhesions  between  cecum,  coils  of 
small  intestines,  omentum,  the  appendix,  the  masses  of  lymph ;  or 
in  the  pelvis  (Deaver),  or  in  any  of  the  erratic  positions  which  the 
appendix  will  occasionally  occupy.  And  such  an  abscess  may  bur- 
row to  great  distances.  Or  the  abscess  may,  through  adhesions, 
perforate  the  walls  of  an  intestinal  loop  or  the  bladder  or  vagina,  and 
so  be  discharged.  General  pyemia  may  occur ;  or  secondary  abscess 
in  various  organs.  In  the  absence  of  retaining  adhesions  the  pus 
escapes  into  the  general  peritoneal  cavity,  setting  up  general  peri- 
tonitis. 

Gangrenous  Appendicitis  is  either  localized  upon  one  part 


544  SURGICAL    DISEASES    OF    CHILDREN 

of  the  appendix,  or  it  involves  more  or  less  of  the  entire  thickness 
of  the  organ.  When  a  gangrenous  appendix  ruptures  there  may 
result  a  local  abscess  walled  off  by  adhesions  as  before  described; 
but  more  frequently  gangrenous  perforation  takes  place  before  any 
such  protective  barriers  have  formed,  and  is  promptly  followed  by 
septic  general  peritonitis.  The  tendency  to  rapid  gangrene  is  very 
strong  in  children. 

Chronic  or  Recurrent  Appendicitis  is  a  repetition  of  one 
or  more  attacks  of  catarrhal  inflammation.  It  results  in  more  or 
less  narrowing  of  the  lumen  of  the  tube,  either  in  portions  or 
throughout  its  entire  length,  and  in  thickening  or  sometimes  shrink- 
ing of  the  size  of  the  appendix.  Any  attack  is  likely  to  take  on  the 
suppurative  form. 

Symptoms  and  Diagnosis. — There  are  three  leading  symptoms 
of  appendicitis,  viz.,  pain,  tenderness,  and  muscular  rigidity.  To 
these  should  be  added  vomiting,  tympanites  and  tumor.  Constipa- 
tion, increased  pulse  rate  and  temperature,  restlessness,  the  urine, 
and  leucoc3'tosis  must  also  be  considered. 

A  typical,  moderately  severe  case  of  catarrhal  appendicitis  be- 
gins with  acute  abdominal  pain,  referred  to  almost  any  part  of  the 
abdomen,  vomiting,  and  localized  tenderness  at  "  McBurney's 
point"  or  at  least  somewhere  along  the  outer  margin  of  the  right 
rectus  muscle  from  the  level  of  the  umbilicus  down.  The  abdominal 
wall  in  that  region  is  in  a  state  of  continuous  tonic  contraction 
which  upon  the  slightest  touch  is  increased  to  a  board-like  rigidity. 
The  bowels  as  a  rule  are  constipated.  The  temperature  elevated 
two  or  three  degrees.  Fever,  vomiting,  and  pain  gradually  subside 
in  from  three  or  four  days  to  a  week,  the  tenderness  on  deep  pres- 
sure remaining  longer. 

An  attack  may  be  either  slighter  or  more  severe  than  this.  It 
may  be  so  slight  and  indefinite  that  no  diagnosis  is  made,  and  in 
some  cases  no  diagnosis  from  an  attack  of  acute  indigestion  could 
be  made.  On  the  other  hand,  without  presenting  any  additional 
symptoms,  it  may  be  more  severe,  with  more  vomiting,  pain,  and 
higher  fever. 

With  atypical  suppurative  appendicitis  the  disease  will  present 
the  symptoms  of  a  severe  case  of  catarrhal  inflammation  to  which 
are  added  a  somewhat  diffuse  induration  that  in  a  few  days  becomes 
more  circumscribed,  but  small,  in  the  region  of  the  appendix.  In 
such  a  case  plastic  lymph  has  caused  adhesions  about  the  site  of  the 
inflammation  and  suppuration  may  not  have  passed  the  coats  of 
the  appendix,  or  if  it  does  pass  outside  of  the  appendix  it  is  still 
a  localized  abscess. 

In  another  case  with  the  same  symptoms  there  may  be  found 
after  two  or  three  days  a  distinct  mass  which  is  very  tender.     Pain 


THE  ABDOMEN,  ITS  MALFORMATIONS  AND  DISEASES      545 

and  fever  continue.  Here  an  abscess  has  formed,  outside  of  the  ap- 
pendix, but  still  a  localized  peritoneal  abscess.  Such  a  case  may 
progress  with  increased  tension  and  greater  accumulation  of  pus 
until  it  bursts  through  into  the  general  peritoneal  cavity,  or  burrows, 
or  perforates  a  viscus,  as  before  described;  or  finds  its  way  to  the 
surface,  probably  in  the  loin.  After  the  formation  of  a  local  abscess 
the  symptoms  will  sometimes  subside  for  a  day  or  a  few  days  and 
give  the  appearance  of  a  turn  toward  recovery — and  then  return 
with  increased  severity  and  progress  more  rapidly  and  dangerously 
than  ever.  Such  a  localized  abscess  should  be  evacuated  before  it 
becomes  large  or  escapes  into  the  general  cavity  or  its  toxines  are 
absorbed.  In  some  cases  the  suppurative  inflammation  spreads  by 
continuity  and  contiguity  and  rapidly  becomes  general ;  or  a  small 
abscess  in  the  appendix  perforates  before  plastic  exudate  has  sealed 
off  the  diseased  area  and  thus  infects  the  general  peritoneal  cavity ; 
or  general  suppurative  peritonitis  follows  the  bursting  or  burrowing 
of  a  localized  peritoneal  abscess  into  the  general  peritoneal  cavity, 
as  before  described. 

Gangrenous  appendicitis  begins  like  an  ordinary  catarrhal  at- 
tack. On  the  second,  third,  and  fourth  day  perforation  occurs,  with 
sudden  severe  abdominal  pain,  vomiting,  symptoms  of  shock,  or 
collapse,  cold  perspiration,  with  a  weak,  rapid,  and  low  tension  pulse, 
followed  by  subnormal  temperature  or  a  sudden  rise  to  105  or  106 
degrees  F.  If  reaction  does  not  occur,  and  within  a  day,  or  some- 
times within  a  few  hours,  there  is  profound  prostration,  with  tympa- 
nites, continued  vomiting  which  becomes  stercoraceous,  pinched  fea- 
tures, leaky  skin,  running  pulse,  collapse  and  death.  Reaction  may 
occur,  allowing  the  patient  to  survive  a  few  days  longer,  during 
which  septic  symptoms  develop.  Fever  continues,  though  not  ex- 
tremely high;  the  abdomen  is  painful,  tympanitic,  and  extremely 
tender  all  over,  with  vomiting,  sweating,  stupor  or  dullness,  or  some- 
times convulsions.  Remission  of  the  symptoms  may  occur,  but  they 
renew  their  force  and  the  patient  succumbs. 

It  is  not  to  be  supposed  that  the  different  pathological  types  of 
the  disease  can  be  always  differentiated  clinically,  nor  that  cases  often 
or  usually  present  the  definite  group  of  symptoms  here  described. 
Even  in  the  adult  the  symptoms  and  course  are  not  always  typical ; 
and  in  children  they  are  very  often  atypical  and  extremely  difficult 
to  determine.  Pain  may  be  present,  but  one  may  be  entirely  at  a 
loss,  from  the  child's  words,  looks,  or  actions,  as  to  where  the  pain 
is  located.  If  the  patient  himself  knows  where  he  feels  the  pain,  it 
may  have  been  reflected.  Often  the  pain  of  appendicitis  is  reflected 
to  the  plexus  of  Meissner  and  AuerlDach  and  felt  in  the  neighbor- 
hood of  the  umbilicus.  If  pain  is  distinctly  located  near  the  um- 
bilicus on  the  right  side,  and  nowhere  else,  it  is  thought  to  be  almost 


546  SURGICAL   DISEASES    OF   CHILDREN 

pathognomonic.  One  is  apt  to  think  of  pain  resulting  from  inflam- 
mation as  being  constant,  while  a  paroxysmal  pain  is  of  spasmodic 
origin.  But  the  pain  of  inflammation  of  the  appendix  is  paroxysmal, 
often  leading  to  the  error  of  considering  it  due  to  colic,  either  in- 
testinal, hepatic,  or  renal,  in  children  especially  intestinal  colic.  But 
colic  has  no  fever  and  no  localized  tenderness. 

Tenderness  in  the  region  of  the  appendix  is  a  valuable  symptom. 
But  the  child  fears  a  touch  anywhere  upon  the  abdomen,  and  does 
not  discriminate  between  pain  and  tenderness. 

Muscular  rigidity — local  rigidity  of  the  abdominal  muscles — is 
one  of  the  most  reliable  symptoms  of  inflammation  beneath.  But  in 
a  child  it  will  often  require  the  greatest  tact  and  skill  in  examining 
to  detect  it.  The  child  dreads  to  be  hurt  and  contracts  the  abdominal 
muscles  as  soon  as  or  even  before  they  are  touched  by  the  examin- 
er's fingers.  Unless  his  confidence  is  gained  or  his  attention  diverted 
it  may  be  impossible  to  tell  whether  rigidity  is  present  or  absent 
from  any  or  all  of  the  abdominal  muscles.  With  pain  referred  to 
the  left  side,  and  with  abscess  in  the  pelvis  there  will  be  muscular 
rigidity  of  both  sides  of  the  lower  abdomen. 

Vomiting  is  a  common  symptom,  though  in  some  cases  it  is 
absent  altogether.  It  is  apt  to  begin  as  early  as  the  pain.  Its  cessa- 
tion or  continuation  is  some  measure  of  the  severity  of  the  case; 
that  is,  in  the  favorable  cases  it  does  not  usually  persist.  Yet  I  have 
known  it  to  last  at  intervals  for  a  week,  and  continue  two  days  after 
the  abscess  was  evacuated  by  operation,  and  the  patient  recovered. 
The  vomitus  consists  simply  of  gastric  contents  early  in  the  case ; 
later  it  is  mixed  with  bile,  and,  lastly,  in  cases  progressing  toward  a 
fatal  termination,  it  becomes  stercoraceous. 

Tympanites  and  constipation  are  generally  present.  The  tympa- 
nites may  result  from  the  constipation,  or  it  may  be  due  to  paralysis 
or  sepsis,  or  obstruction  by  bands  of  adhesions.  Deaver  quotes 
Richardson's  suggestion  of  differentiating  by  auscultation  between 
a  collection  of  gas  from  paralysis  of  the  intestines.  With  the  former, 
peristaltic  movements  may  be  heard,  but  not  with  the  paralysis.  A 
persistently  distended  abdomen  and  vomiting  are  a  very  unfavorable 
combination  of  symptoms. 

Diarrhea  is  unusual,  and  generally  turns  one's  thoughts  toward 
gastro-enteritis ;  yet  it  may  occur  in  appendicitis. 

Tumor  may  be  present  in  twenty-four  or  forty-eight  hours,  or 
later,  or  it  may  not  be  present  at  all,  even  in  a  severe  case.  It  may 
be  quite  diffuse,  or  distinctly  circumscribed.  Two  procedures  valu- 
able in  the  examination  of  obscure  cases  are  frequently  omitted.  One 
is  anesthesia  and  the  other  is  rectal  examination.  In  a  fractious  or 
nervous  child  it  may  be  entirely  impossible  to  form  an  idea  whether 
tumor  is  present,  until  the  patient  is  quieted  by  a  few  whiffs  of 


THE   ABDOMEN,  ITS   MALFORMATIONS   AND  DISEASES      547 

chloroform.  Then  the  shallow  abdominal  cavity  and  thin  abdominal 
walls  afford  conditions  favorable  for  palpation  and  percussion. 
Rectal  examination  with  or  without  anesthesia  should  never  be 
omitted  in  any  case  of  doubt.  By  this  means  tumefaction  may  be 
discovered,  abscess  sometimes  recognized,  or  tenderness  localized, 
when  the  same  could  not  be  accomplished  through  the  abdominal 
walls.  The  finger  reaches  much  farther,  anatomically,  in  the  rectum 
of  a  child.  In  all  these  examinations  extreme  caution  and  gentleness 
are  necessary,  remembering  the  liability  of  tearing  adhesions  or 
bursting  softened  tissues. 

The  temperature  is  not  a  reliable  index  to  the  condition  of  the 
patient.  There  may  be  a  considerable  amount  of  fever — 102  or  103 
degrees  in  a  catarrhal  case  that  will  end  favorably ;  and  there  may  be 
gangrene  without  any  alarming  temperature.  A  sudden  drop  of 
temperature  is  unfavorable ;  and  a  more  gradual  decline  does  not 
always  indicate  that  all  is  going  well. 

The  pulse  is  of  more  importance  as  an  index,  if  not  of  the 
progress  of  the  disease,  at  least  of  the  strength  of  the  patient.  But 
there  is  nothing  reliable  about  pulse  or  temperature  to  aid  in  dif- 
ferential diagnosis. 

Frequent  micturition  is  a  common  symptom  and  is  apt  to  sug- 
gest renal  colic  or  other  disease  of  the  urinary  organs  as  an  explana- 
tion of  the  pain  and  other  symptoms.  It  is  due  either  to  irritation 
of  the  nerves  of  the  bladder  when  the  inflamed  appendix  is  in  close 
proximity,  or  to  irritation  communicated  through  the  sympathetic 
nervous  system.  The  urine  is  generally  diminished  in  total  amount 
and  sometimes  contains  indican  and  albumen. 

Alteration  of  respiration  is  not  regarded  as  of  much  importance 
in  the  adult.  But  in  the  infant  and  young  child,  in  whom  the  type  of 
respiration  is  abdominal,  a  fixation  of  the  abdominal  muscles  and 
diaphragm  and  a  change  to  costal  respiration  is  more  noticeable.  It 
might  be  thought  to  indicate  respiratory  disease.  Distension  of  the 
abdomen  also  may  quicken  the  respiration  rate  and  even  cause  a 
grunting  expiration  resembling  that  of  pneumonia.  The  diagnosis 
of  appendicitis  from  basal  pneumonia,  or  diaphragmatic  pleurisy  is 
not  always  easy,  but  mistakes  would  occur  less  often  if  the  possibility 
of  appendicitis  in  children  were  borne  in  mind,  and  the  muscular 
rigidity,  tenderness,  and  tumescence  searched  for. 

Restlessness  is  characteristic  of  childhood,  but  if  a  child  with 
symptoms  of  appendicitis  becomes  extremely  restless,  it  denotes  the 
presence  of  pus.     (Deaver.) 

In  children  the  so-called  larvate  form  of  appendicitis  is  rather 
common.  If  a  child  is  not  at  the  moment  severely  sick  or  weak  or 
in  pain,  he  wants  to  be  up  and  about,  and  soon  forgets  or  disregards 
minor  symptoms.    Within  a  few  days  of  this  writing  I  have  operated 


548  SURGICAL   DISEASES    OF    CHILDREN 

on  a  boy  of  five  years,  finding  a  foul-smelling  appendical  abscess  ex- 
tending over  the  brim  into  the  pelvis.  On  the  morning  set  for  the 
operation  he  was  up  and  clothed  as  usual  and  would  have  walked 
down  stairs  to  take  the  street-cars  for  the  hospital  had  he  been 
allowed. 

The  diagnosis  from  acute  indigestion  and  from  acute  obstruc- 
tion is  often  very  difficult  early  in  the  case.  For  example,  in  one  of 
my  cases,  a  girl  of  twelve  years  was  attacked  with  cramps  in  the 
abdomen  and  vomiting.  There  was  constipation  and  the  entire  ab- 
domen was  painful,  tender,  and  tympanitic.  Deep  palpation  was  im- 
possible. Fever  rose  promptly  to  102.5  degrees  F.,  pulse  124.  She 
had  eaten  a  quantity  of  raw  prunes  and  also  accidentally  swallowed  a 
prune  stone.  The  use  of  copious  enemata  and  of  repeated  small 
doses  of  calomel  and  broken  doses  of  Rochelle  salts  started  the 
bowels  and  they  discharged  scybalous  masses  and  a  quantity  of 
prune  skins.  By  the  third  day  the  illness,  pain,  and  fever  had  sub- 
sided, and  also  the  tympanites.  The  girl  seemed  better.  But  now 
induration  could  be  felt  in  the  right  iliac  region,  and  the  tenderness 
which  had  seemed  general  localized  here.  Also  muscular  rigidity. 
Operation  confirmed  the  revised  diagnosis  of  appendical  abscess. 

Appendicitis  is  sometimes  mistaken  for  typhoid  fever  and  even 
for  hip  disease.  Intussusception  has  some  symptoms  in  common 
with  appendicitis,  and  so  also  has  hernia. 

Leucocytosis  is  said  to  be  invariably  present  in  perforative  ap- 
pendicitis. But  by  the  time  it  appears  there  are  usually  present 
unmistakable  symptoms,  which  leucocytosis  is  not.  In  long-continued 
appendicitis  hemoglobin  is  reduced  to  60  or  as  low  as  40  per  cent., 
and  the  erythrocytes  to  two  millions  or  three  millions  per  c.  c. 

In  chronic  appendicitis  there  is  often  a  history  of  one  or  more 
previous  attacks,  though  these  will  often  be  attributed  to  indigestion 
or  something  else.  Pain  or  discomfort  or  uneasiness  is  felt  in  the 
right  iliac  region.  Pain  may  be  referred  to  a  point  just  at  the  right 
of  the  umbilicus.  There  is  generally  gaseous  distension  of  the 
cecum,  and  constipation,  which  may  alternate  with  diarrhea.  There 
is  frequently  neurasthenia  or  "  general  debility,"  which  in  children 
takes  the  form  of  irritability  or  peevishness.  There  are  frequent 
disturbances  of  digestion ;  and  indiscretions  in  diet  often  bring 
on  acute  exacerbation  of  the  inflammation.  But  the  most  valuable 
symptoms  are  tenderness  localized  in  the  region  of  the  appendix; 
and  pain  excited  by  palpation  at  that  point.  Exercise  may  cause 
the  pain.  The  appendix  may  sometimes  be  felt  enlarged,  though  in 
other  cases  it  undergoes  contraction.  A  more  diffuse  chronic  indura- 
tion or  the  tumefaction  of  a  chronic  abscess  may  be  felt. 

Prognosis. — The  prognosis  depends  so  much  upon  early  diag- 
nosis and  the  line  of  treatment  adopted  that  general  prognosis  is 


THE  ABDOMEN,  ITS   MALFORMATIONS   AND  DISEASES      549 

impossible.  Some  writers  claim  that  95  per  cent,  of  all  cases  will 
recover  under  medical  treatment.  But  the  men  who  have  had  most 
experience  with  the  disease  will  not  agree  to  this  statement.  Rib- 
bert  places  the  number  of  complete  recoveries  under  medical  treat- 
ment at  16  in  400.  A  somewhat  larger  number  than  this  apparently 
recover.  But  according  to  Dorfer,  of  those  who  apparently  recover 
without  operation  30  per  cent,  have  a  recurrence.  Catarrhal  ap- 
pendicitis may  recover.  But  no  one  can  be  absolutely  sure  that  it  is 
only  catarrhal  appendicitis ;  nor  that  it  will  remain  only  catarrhal ; 
nor  if  recovery  occurs  for  the  present,  that  the  disease  will  not  recur. 
Cases  that  recover  with  adhesions  may  have  obstruction  of  the  bowels 
from  the  adhesions.  If,  early  in  the  attack,  the  bowels  respond 
promptly  to  laxatives  and  are  thoroughly  emptied,  the  prognosis  is 
thereby  improved.  A  case  operated  early  before  there  is  perforation 
or  peritonitis,  or  abscess,  that  is,  while  the  disease  is  entirely  within 
the  appendix,  will  probably  recover,  unless  it  is  quite  a  young  child. 
The  prognosis  in  all  young  children  is  uncertain.  Older  children 
do  better,  even  better  than  adults.  Cases  operated  when  there  is  a 
localized  abscess,  and  no  symptoms  of  general  peritonitis,  general 
septicemia,  or  pyemia,  generally  recover.  If  either  of  the  other  con- 
ditions are  present  the  prognosis  is  bad.  Cases  having  general 
peritonitis  at  the  time  of  the  operation  have  recovered,  but  this  is 
not  the  probable  termination.  More  cases  die  of  general  peritonitis 
than  from  any  other  cause ;  but  many  end  in  pyemia.  The  virulence 
of  the  infection  has  a  very  important  bearing  on  the  result  in  cases 
treated  medically.  In  cases  treated  surgically  the  prognosis  is  better 
the  earlier  the  operation.  If  abscess  has  formed,  the  prognosis  is 
not  as  good  as  if  the  operation  were  made  before  abscess  formation. 
And  if  general  peritonitis  is  present  with  a  rapid  compressible  pulse 
and  profuse  perspiration,  operation  will  most  likely  avail  nothing ; 
and  to  refrain  from  operating  offers  about  as  little  hope. 

Treatment. — From  what  has  been  said  of  the  pathology, 
symptoms,  and  course,  diagnosis,  and  prognosis,  the  line  of  treat- 
ment Will  readily  be  inferred.  Medical  treatment  is  to  be  followed 
only  until  a  diagnosis  can  be  made ;  then  the  treatment  is  surgical. 
Yet  proper  medical  treatment  can  do  a  great  deal  of  good,  and  what 
is  equally  important,  can  avoid  a  great  deal  of  harm.  Rest  in  bed 
is  imperative,  from  the  moment  appendicitis  is  suspected.  To  empty 
the  bowels  is  the  first  object.  Pain  and  vomiting  may  be  present, 
but  these  are  often  relieved  better  by  emptying  the  intestinal  tract 
than  in  any  other  way.  To  clear  the  bowels  there  is  nothing  better 
than  castor-oil ;  but  it  is  often  not  tolerated  by  the  stomach.  In  the 
presence  of  vomiting,  calomel  and  sodium  bircarbonate  are  better, 
usually  in  small  and  quickly  repeated  doses,  perhaps  one-tenth  of  a 
gram  at  a  dose  every  half-hour.     After  half  a  grain  or  a  grain  or 


550  SURGICAL   DISEASES    OF   CHILDREN 

more  has  been  taken  it  can  be  followed  with  castor-oil  or  with  a 
saline  laxative,  such  as  citrate  of  magnesia,  or  Rochelle  salts.     In 
the  meantime,   however,   the   colon   should  have   been   cleared  by 
enemata.    Also  an  icebag  should  have  been  applied  over  the  right 
iliac  region,  and  a  small  mustard  plaster  over  the  epigastrium.    The 
most  important  thing  to  refrain  from  doing  is  the  giving  of  opiates 
in  any  form.    Opiates  lock  up  the  intestines,  and  they  also  obscure 
the  symptoms  and  give  an  appearance  of  safety  that  is  completely 
opposite  to  the  true  condition.    Pain  and  tenderness  may  be  relieved 
without  doing  any  harm  by  the  use  of  the  solid  extract  of  belladonna 
one  drachm,  to  glycerine  one  ounce.     The  tender  area  in  the  iliac 
region  should  be  smeared  (after  thoroughly  cleansing  the  skin)  with 
this  preparation,  and  covered  with  oil  silk.     The  icebag  can  still 
be  used  outside  of  this  dressing.    The  consensus  of  opinion  among 
those  who  have  closely  studied  this  disease  is,  that  in  all  patients, 
once  the  appendix  is  inflamed,  there  is  no  safety  but  in  its  removal ; 
and  the  sooner  this  is  done  the  better.    In  my  opinion  these  principles 
are  more  especially  true  of  children  than  of  adults,  and  the  younger 
the  child  the  more  urgent  the  necessity  of  prompt  interference.    The 
reasons  have  already  been  stated  elsewhere,  namely,  their  weaker 
resistance  to  the  progress  of  the  disease,  less  tendency  to  wall  off 
the  inflamed  area  with  protecting  adhesions,  greater  tendency  to 
rapid  perforation,  and  to  general  peritonitis.     Also  the   fact  that 
children,  as  compared  with  adults,  bear  deprivation  of  food  badly, 
and  this  is  a  disease  in  which  the  amount  of  food  must  be  cut  low. 
The  longer  this  continues  the  lower  will  be  the  state  of  the  child's 
nutrition  and  recuperative  power.     The  most  favorable  time  for 
operation  is  early  in  the  case  while  the  disease  is  still  confined  to  the 
appendix.    If  not  seen  or  not  diagnosed  until  later  when  tumescence 
betrays  the  presence  of  localized  peritonitis  around  the  appendix, 
the  most  favorable  time  for  operation  has  been  lost.     There  is  a 
small  number  of  cases  in  which  a  delay  of  a  few  hours  or  a  day 
or  two  will  allow  more  time  for  adhesions  to  form,  and  an  operation 
can  be  made  with  greater  safety,  so  far  as  local  conditions  are  con- 
cerned.    But  some  of  these  cases  which  apparently  have  subsided 
and  admit  of  safe  delay  will  suddenly  become  most  violent  and 
dangerously  active.     It  is  practically  impossible  to  tell  which  cases 
can  safely  wait  and  which  cannot,  and  so  few  of  them  will  terminate 
in  resolution  that  the  risk  of  waiting  is  not  justifiable.     This  brings 
us  back  to  the  rule  that  in  children  early  operation  in  all  cases  is 
the  safest  line  of  treatment.     If  the  parents  will  not  give  their  con- 
sent to  operation,  or  for  any  reason  it  is  not  done,  and  the  case 
recovers  for  the  time  being,  the  probability  of  a  recurrence  should 
be  explained,  and  operation  in  the  interval,  which  is  a  more  favor- 
able time  than  during  an  attack,  should  be  urged. 


THE   ABDOMEN,  ITS   MALFORMATIONS   AND  DISEASES      551 

Operation. — There  are  four  principal  conditions  under  which 
operation  for  appendicitis  is  done.  First,  early  in  the  attack  when 
the  disease  is  still  confined  to  the  appendix.  Secondly,  when  abscess 
has  formed  but  is  limited  by  adhesions.  Thirdly,  in  the  presence  of 
general  peritonitis  or  where  abscess  has  recently  escaped  into  the 
peritoneal  cavity.  Fourthly,  in  the  interval  of  the  exacerbations  of 
chronic  or  recurrent  appendicitis. 

All  of  these  operations  are  done  upon  the  strictest  principles 
of  antiseptic  surgery.  Even  in  cases  thought  to  be  purulent  or 
septic,  care  is  taken  not  to  make  matters  worse  by  introducing  new 
infective  agents  or  by  distributing  further  those  already  in  the  sys- 
tem. There  are  numerous  methods  of  operating  and  many  modifica- 
tions of  each  method.  I  shall  describe  only  such  as,  in  my  judgment 
and  experience,  are  best  adapted  to  meet  the  conditions  in  children. 

The  patient  receives  a  bath  of  hot  water  and  soap  and  a  complete 
change  of  clothing  and  bed  linen.  The  abdomen,  groin,  and  right 
loin  are  thoroughly  scrubbed  with  green  soap  or  ethereal  soap  and 
hot  water,  applied  with  a  piece  of  flannel  or  gauze,  and  thoroughly 
rinsed  with  sterile  water.  This  is  followed  by  ether  or  alcohol  and 
bichloride,  and  then  with  a  compress  of  gauze  wet  with  bichloride 
solution  I  to  1000,  which  covers  the  parts  during  the  adjustment  of 
the  sterile  sheets  and  towels.  This  would  be  the  preparation  for  an 
emergency  operation.  If  there  is  time  to  spare,  as  in  an  interval 
operation,  such  preparation  should  be  made  on  the  previous  day, 
and  the  bichloride  compress,  i  to  2000,  covered  with  cotton  and  a 
binder  left  on  over  night.  Washing  with  alcohol,  followed  by  bi- 
chloride solution  and  then  sterile  water,  is  repeated  just  before  the 
operation.  Care  should  be  taken  to  protect  the  child  from  cold  and 
shock  by  having  the  limbs  wrapped  in  cotton  and  all  parts  not  neces- 
sarily exposed  well  covered.  After  washing,  the  patient  should  not 
be  allowed  to  lie  upon  a  wet  surface  during  the  operation.  Every- 
thing underneath  should  be  dry  and  warm,  and  hot-water  bottles 
should  contribute  their  warmth.  (43) 

One  uses  either  the  McBurney  or  the  simple  incision.  The  Mc- 
Burney  incision  is  a  little  more  difficult  and  takes  a  little  more  time 
(not  merely  to  make  the  incision,  but  to  work  through  it)  than  the 
simple  incision,  and  unless  the  operator  is  quite  familiar  with  it 
should  be  reserved  for  older  children  who  are  also  in  good  condition 
for  operation.  It  is  not  suited  for  pus  cases.  But  it  has  the  ad- 
vantage of  being  very  seldom  followed  by  ventral  hernia.  In  the 
McBurney  operation  the  opening  is  made  half  way  between  the 
right  linea  semilunaris  and  the  anterior  iliac  spine.  The  incision 
is  curved,  with  the  convexity  outward.  No  muscle  is  cut,  but  only 
the  fasciae.  Each  muscle  is  divided  by  blunt  dissection  in  the  direc- 
tion of  its  fibers.    Thus  the  external  oblique,  and  the  internal  oblique 


552  SURGICAL   DISEASES    OF   CHILDREN 

and  transversalis,  are  successively  opened  and  held  by  retractors, 
thus  exposing  the  transversalis  fascia,  which  is  divided  in  the  same 
direction  as  the  fibers  of  the  internal  oblique  and  transversalis.  The 
incision  in  the  peritoneum  is  transverse.  The  incision  is  now  held 
open  by  one  or  two  pairs  of  retractors.  The  anterior  longitudinal 
muscular  band  of  the  cecum  is  traced  downward,  the  appendix 
brought  up  into  the  wound  and  removed,  the  stump  is  invaginated. 
The  peritoneum  is  closed  with  a  continuous  catgut  suture,  and  the 
incision  of  the  transversalis  fascia  also  closed  in  the  same  manner. 
The  separated  fibers  of  the  internal  oblique  and  transversalis  are 
allowed  to  come  together  and  secured  by  a  couple  of  sutures.  The 
incision  of  the  aponeurosis  of  the  external  oblique  is  closed  by  con- 
tinuous sutures  of  catgut  or  kangaroo  tendon,  and  the  skin  incision 
by  continuous  subcutaneous  catgut  suture.  The  wound  is  then  sealed 
with  iodoform  collodion. 

The  simple  incision  is  made  in  the  direction  of  the  right  linea 
semilunaris,  just  at  the  outer  margin  of  the  rectus  muscle.  It  has 
one-third  of  its  length  above  a  line  drawn  from  the  anterior  superior 
spine  of  the  ilium  to  the  umbilicus.  If,  from  the  presence  of  tumor 
and  the  other  symptoms,  one  is  confident  of  finding  a  localized  ab- 
scess, it  is  well  to  make  the  incision  farther  to  the  right,  perhaps 
half  way  between  the  semilunar  line  and  Poupart's  ligament  and 
parallel  with  the  latter.  This  keeps  the  operation  farther  away  from 
the  adhesions  which  wall  ofl:  the  abscess,  and  perhaps  affords  bet- 
ter drainage.  The  length  of  incision  usually  advised  in  adults  is 
three  inches.  Some  operators  think  two  inches  is  enough.  Two 
inches  certainly  is  enough  in  children  in  most  cases  and  sometimes 
less  will  do.  Their  abdominal  walls  are  comparatively  thin  and  the 
cavity  not  deep.  But  if  there  are  extensive  adhesions  of  the  ap- 
pendix which  cannot  be  reached  or  brought  up  into  the  wound,  en- 
large the  incision  as  much  as  is  necessary  to  do  the  work.  All 
bleeding  should  be  controlled  with  pressure  forceps  before  the  peri- 
toneum is  opened.  Care  should  be  taken  lest  distended  or  even  ad- 
herent bowel  be  opened  into  immediately  with  the  peritoneal  incision. 
The  peritoneum  being  picked  up  between  two  pairs  of  tissue  forceps 
is  incised  a  distance  of  one  inch.  The  index  finger  carefully  intro- 
duced now  cautiously  and  gently  explores.  One  has  trembled  to  see 
a  brawny  pair  of  fingers  plunged  into  a  child's  abdominal  cavity  and 
thrust  hither  and  thither.  If  it  is  an  interval  case  the  cecum  can 
now  be  picked  up  and  traced  down  to  the  appendix,  which  can  be 
brought  out  at  the  opening  and  amputated.  This  is  done  by  first 
transfixing  the  meso-appendix  at  its  base,  tying  it  off  with  catgut 
and  then  removing  it  with  scissors.  In  an  older  child  in  good  con- 
dition for  operation  time  may  now  be  taken  to  form  a  cuff"  of  the 
serous  coat  of  the  appendix.    This  is  cut  around  the  circumference 


THE  ABDOMEN,  ITS   MALFORMATIONS   AND  DISEASES      553 

of  the  appendix  a  quarter  of  an  inch  from  the  wall  of  the  cecum 
and  dissected  back  to  that  viscus.  The  appendix  is  then  ligated  with 
silk  and  cut  off.  The  mucous  lining  of  the  stump  is  then  scraped 
with  a  small  curette  and  touched  with  a  solution  of  bichloride  of 
mercury,  i  to  2000,  and  then  with  a  solution  of  carbolic  acid,  i  to  60. 
The  cuff  is  then  folded  in  by  stitching-  with  fine  silk  in  a  round 
needle.  The  stump  is  then  invaginated  into  the  end  of  the  cecum, 
where  it  is  held  by  continuous  Lembert  sutures.  A  simpler  method, 
more  quickly  done,  and  therefore  often  useful  with  children,  omits 
the  formation  of  the  cuff.  The  appendix  is  simply  ligated  and  cut 
off.  The  mucous  lining  of  the  stump  is  curetted  and  touched  with 
pure  carbolic  acid  and  the  excess  of  acid  wiped  off.  The  cut  ends 
of  the  stumps  of  the  meso-appendix  and  of  the  appendix  are  united 
face  to  face  by  a  few  stitches,  or  sometimes,  but  not  always,  the 
appendical  stump  is  invaginated  by  Lembert  or  a  purse-string  suture. 
If,  however,  abscess  is  present  it  is  better  to  enlarge  the  peritoneal 
incision  to  the  size  of  the  external  wound  and  introduce  a  wall  of 
strips  of  sterile  gauze  along  the  inner  side  of  the  wound,  shutting 
off  access  to  the  general  peritoneal  cavity,  as  one  explores  deeper  and 
deeper.  The  finger  finds  the  abscess,  which  wells  up  and  flows  or 
is  mopped  out  with  gauze  sponges.  At  this  point  opinions  of  opera- 
tors differ  as  to  the  next  step.  Some  say  the  operation  is  not  com- 
plete unless  the  appendix  is  removed,  and  they  proceed  to  explore 
and  find  and  then  to  remove  it  as  if  no  pus  were  present.  Others 
are  content  to  introduce  drainage  and  end  the  operation.  If  the  ap- 
pendix comes  readily  under  the  fingers  and  is  easily  brought  into 
the  wound,  I  remove  it.  But,  whatever  one  may  do  in  case  of  an 
adult,  I  consider  it  bad  practice  in  a  child  to  make  any  extended 
search  for  the  appendix  in  a  pus  case.  I  realize  that  in  one  sense 
the  operation  is  not  complete.  I  realize,  too,  that  many  a  surgeon  is 
as  anxious  to  add  another  appendix  to  his  collection  as  an  Indian 
is  to  hang  another  scalp  at  his  girdle  as  a  proof  of  his  prowess ;  but 
the  surgeon  has  no  right  to  risk  his  patient's  life  for  this  purpose. 
If  the  appendix  must  be  removed,  which  is  not  always  the  case,  it 
can  be  better  done  at  some  future  time.  It  is  a  very  poor  time  to 
do  it  with  pus  separated  from  the  peritoneal  cavity  by  only  weak  and 
scanty  adhesions,  which  may  easily  be  parted  in  the  manipulations 
necessary  for  the  appendicectomy.  Besides,  no  operation  in  a  child 
should  be  prolonged  when  it  can  possibly  be  avoided.  The  abscess 
should  be  wiped  out  as  clean  as  may  be  with  gauze  sponges ;  or  if 
the  child  is  very  weak  and  bad,  time  should  not  be  consumed  even 
for  this.  An  ordinary  rubber  drainage  tube  or  preferably  the  rub- 
ber tissue  drainage  tube  with  a  wick  of  iodoform  gauze  very  lightly 
filling  it  should  be  passed  to  the  bottom  of  the  cavity  wherever  that 
may  be.     The  incision  may  be  partly  closed,  leaving  space  for  the 


554  SURGICAL   DISEASES    OF   CHILDREN 

drainage,  and  abundant  moist  gauze  and  dry  cotton  dressing  should 
be  applied. 

If  pus  is  free  in  the  abdominal  cavity  it  should  be  flooded  out 
with  hot  sterile  normal  saline  solution.  If  the  patient  is  an  older 
child  and  in  fit  condition  to  withstand  further  work,  and  the  appen- 
dix can  be  reached  and  detached  without  too  much  delay  and  dissec- 
tion, it  may  be  removed,  for  in  such  a  case  manipulations  do  not  en- 
danger the  spread  of  pus ;  it  is  only  a  question  of  shock.  Ordinarily 
it  is  better,  after  flushing  out,  to  introduce  strips  of  gauze  in  various 
directions  into  the  abdomen,  their  ends  emerging  at  the  wound; 
drainage  to  the  location  of  the  appendix ;  introduce  sutures  between 
the  gauze  strips,  but  leave  most  of  them  untied;  and  apply  the 
dressings. 

In  closing  the  simple  incision  the  peritoneum  is  united  with 
continuous  catgut  suture,  the  muscular  layers  with  simple  or  mat- 
tress suture  of  kangaroo  tendon,  chromicized  catgut  or  silk,  and  the 
skin  with  subcutaneous  or  ordinary  suture  of  silkworm  gut.  Moist 
bichloride  gauze  and  dry  cotton  should  be  held  securely  in  place  with 
adhesive  straps  almost  encircling  the  body.    A  binder  covers  all. 

After  Treatment  is  important.  The  child  should  be  put  to  bed 
with  hot-water  bottles.  The  room  should  be  quiet  and  he  should  be 
well  watched.  It  is  usually  safer  to  restrain  children  by  tying,  or 
pinning  clothing  to  mattress.  They  toss  about.  Some  will  pull  at 
the  dressings.  I  have  had  a  boy,  within  a  few  hours  after  his  opera- 
tion, while  the  nurse  was  attending  for  a  moment  to  another  patient, 
jump  out  of  bed,  run  out  of  the  ward  and  down  the  hall  in  search 
of  a  drink  of  water.    No  harm  came  of  it,  but  there  might  have. 

Vomiting  from  the  anesthetic  should  be  avoided  as  much  as 
possible.  The  use  of  oxygen  with  and  after  the  anesthetic  aids  in 
this.  Also  free  air  in  the  room  and  an  empty  stomach  for  hours. 
A  normal  saline  enema  or  a  coffee  saline  on  putting  to  bed  relieves 
both  shock  and  thirst.  Hypodermoclysis  of  normal  saline  is  useful 
but  painful,  and  especially  if  any  large  quantity  is  used  slowly ;  but 
a  couple  of  ounces  may  be  put  under  the  skin,  while  still  under  the 
anesthetic.  Use  strychnia  or  camphor  if  necessary.  No  morphine 
should  be  used.  The  urine  should  be  watched.  The  usual  rule  after 
anesthesia,  of  allowing  nothing  by  the  mouth  for  at  least  four  hours, 
should  be  observed.  Then  bits  of  ice  may  be  tried  or  a  teaspoon  of 
hot  water.  If  the  stomach  continue  irritable,  nutrient  enemata 
should  be  promptly  resorted  to,  using  peptonoids,  pancreatized  milk, 
and  the  like.  For  tympanites,  rectal  injections  of  emulsion  of  asa- 
fetida.  In  clean  cases,  that  is,  no  pus,  and  the  wound  closed,  if  all 
goes  well,  without  rise  of  temperature  or  pulse  and  no  pain  or 
tension,  no  dressing  is  necessary  for  at  least  five  days.  The  wound 
may  have  closed  perfectly  and  stitches  may  be  removed.    Or  by  this 


THE  ABDOMEN,  ITS   MALFORMATIONS   AND  DISEASES      555 

time,  unfortunately,  pus  may  have  developed  and  the  case  must  be 
treated  accordingly. 

In  drainage  with  a  tube  the  tube  should  be  kept  free  of  any 
collection  of  fluid,  and  not  withdrawn  until  nothing  more  collects. 
Gauze  left  for  drainage  or  for  walling  off  would  best  not  be  dis- 
turbed for  two  days ;  and  then  should  be  well  soaked  with  warm 
boric  solution  and  very  cautiously  removed.  After  irrigating  the 
cavity  without  the  least  force  or  pressure  it  is  again  packed  with 
iodoform  gauze  covered  with  moist  boric  or  bichloride  gauze,  cot- 
ton, straps  and  binder  and  left  for  another  two  days.  Drainage  is 
withdrawn  if  pus  formation  ceases  or  the  cavity  closes  from  the 
bottom  by  granulation  and  approximation  of  its  walls.  Finally 
sutures  or  adhesive  straps  approximate  the  wound  margins  and 
hasten  their  closure. 

CHRONIC    (NON-TUBERCULAR)    PERITONITIS 

Chronic  peritonitis,  either  fibrinous,  serous,  or  suppurative,  may 
follow  the  acute  form.  Chronic  localized  peritonitis  may  occur  as 
a  result  of  disease  of  any  organ  which  the  peritoneum  covers,  or 
from  the  growth  of  tumors  in  the  abdomen.  But  there  may  occur 
in  rare  instances  a  form  of  chronic  peritonitis  that  is  not  due  to  any 
of  these  causes  nor  sometimes  to  any  known  cause.  Measles,  ex- 
posure to  cold  and  wet,  rheumatism,  and  remote  hereditary  syphilis 
have  been  listed  as  causes.  Some  persist  in  the  opinion  that  the 
disease  is  after  all  a  result  of  tubercular  infection  in  which  the 
bacilli  have  disappeared.  That  some  general  cause  is  at  work  seems 
to  be  indicated  by  the  occasional  presence  of  chronic  pleurisy  in 
the  same  case. 

Pathology. — The  most  obvious  finding  is  a  large  amount  of 
ascitic  fluid,  usually  clear  and  slightly  greenish.  There  may  be 
flakes  of  fibrin  and  some  adhesions.  Disease  of  some  of  the  ab- 
dominal organs  covered  by  the  peritoneum  may  be  found  or  a 
tumor  the  presence  of  which  has  excited  the  peritoneal  inflammation. 

Symptoms. — There  may  be  no  symptoms  whatever  until  the  en- 
largement of  the  abdomen  is  noticed;  or  there  may  be  a  period  of 
malassimilation  and  general  debility.  Occasionally  a  history  of 
irregular  slight  abdominal  pain  and  tenderness  can  be  elicited,  and 
sometimes  irregularity  of  the  bowels — either  constipation  or  diar- 
rhea, or  these  may  alternate.  On  examination  the  abdomen  is  found 
to  contain  fluid,  which  gives  the  wave  of  fluctuation  on  percussion, 
and  if  the  cavity  is  not  too  tensely  filled  with  it,  shifts  its  position 
when  the  position  of  the  child  is  changed.  If  the  distension  is  great 
it  may  be  impossible  to  outline  liver,  or  spleen,  or  any  tumor ;  the 
umbilicus  will  be  protuberant ;  and  the  abdomen  remains  dull  with 
the  patient  changed  to  any  position ;  and  the  superficial  veins  are 


S56  SURGICAL   DISEASES    OF   CHILDREN 

prominent  over  the  abdomen.  Sometimes  the  lower  extremities  are 
swollen  from  pressure  upon  the  vena  cava  inferior. 

Fever  never  runs  high  and  may  be  nearly  absent  at  times. 

Diagnosis  and  Prognosis. — Ascites  or  general  anasarca  from 
disease  of  heart,  liver,  or  kidneys  should  be  carefully  excluded,  by 
the  physical  signs,  testing  the  urine,  et  cetera.  Without  a  tuberculin 
test  it  may  be  impossible  to  exclude  tubercular  peritonitis.  However, 
after  several  weeks  the  simple  form  of  peritonitis  will  usually  gradu- 
ally subside  and  recovery  ensue;  and  no  tubercular  disease  develop 
in  the  peritoneum  or  elsewhere  in  the  body.  In  other  cases  the 
ascites  increases  and  the  patient  declines  to  a  fatal  end,  sometimes 
from  the  tumor  or  organic  disease  which  gave  rise  to  the  peri' 
tonitis. 

Treatment. — As  in  other  forms  of  inflammation,  the  first  indica- 
tion is  rest.  This  is  best  obtained  by  confining  the  patient  to  bed, 
although  not  necessarily  to  the  house.  The  bed,  couch,  or  Brad- 
ford frame  can  be  carried  out  upon  a  porch  or  lawn.  Tonics  and 
sometimes  alteratives  are  useful,  such  as  syrup  of  the  iodide  of  iron ; 
or  Basham's  mixture,  which  combines  a  diuretic  with  the  ferrugin- 
ous tonic.  If  the  fluid  remains,  or  if  it  increases  so  that  the  dis- 
tension interferes  with  the  circulation  and  to  some  extent  with  the 
respiration,  tapping  is  indicated.  This  may  be  done  either  with 
the  trocar  and  canula  or  with  the  aspirating  apparatus;  but  with 
either  method  strict  antiseptic  precautions  should  be  employed.  Re- 
peated tappings  may  be  necessary  if  the  fluid  reaccumulates ;  or 
laparotomy  may  be  performed  as  described  under  tubercular  peri- 
tonitis, with  good  prospects  of  a  favorable  result.  (44) 

TUBERCULAR   PERITONITIS 

This  is  almost  synonymous  with  chronic  peritonitis,  for  chronic 
peritonitis  without  tuberculosis,  although  it  may  occur,  is  infrequent, 
and  by  some  is  thought  to  be  due  to  the  presence  of  tubercle  bacilli 
which  are  destroyed  in  the  process.  Yet  not  all  tubercular  peri- 
tonitis is  chronic.  It  is  by  no  means  an  uncommon  disease,  and 
prevails  at  all  ages,  though  seldom  in  the  first  year.  It  m.ay  be 
primary,  but  in  most  cases  it  is  one  of  the  local  manifestations  of  a 
general  infection. 

Several  forms  of  tubercular  peritonitis  are  described.  First 
the  acute  miliary,  second  the  ascitic,  third  the  fibro-plastic,  and  fourth 
the  ulcerative. 

The  Acute  Miliary  Form. — In  the  first  form  there  are  found 
miliary  tubercles  distributed  over  the  peritoneum,  and  very  little 
evidence  of  local  inflammation.  The  peritoneal  involvement  sel- 
dom attracts  attention  during  life,  being  overshadowed  by  the  gen- 
eral infection  which,  as  a  rule,  soon  terminates  the  case  in  death. 


THE  ABDOMEN,  ITS   MALFORMATIONS   AND  DISEASES      557 

The  Ascitic  Form. — The  second  or  ascitic  form  also  presents 
miliary  tubercles,  but  thickly  placed  over  the  peritoneum,  the  sur- 
face of  the  intestine  and  the  mesenteries,  the  omentum  and  the 
serous  coverings  of  all  the  viscera.  There  are  evidences  of  inflam- 
mation, and  of  some  plastic  exudation,  which  is  small  in  amount 
as  compared  with  the  ascitic  fluid  which  is  present.  This  fluid 
may  be  clear  and  serous,  of  a  greenish-yellow  color,  if  the  infection 
is  purely  tubercular;  or  it  may  be  sero-purulent  when  pyogenic 
organisms  also  have  been  present ;  or  it  may  be  stained  with 
blood.  The  disease  runs  a  subacute  or  chronic  course  of  a  few 
weeks,  or  more  often  of  three  or  four  or  more  months,  with  one  or 
two  degrees  of  fever,  progressive  weakness  and  moderate  loss  of 
weight. 

Symptoms  and  Diagnosis. — The  symptoms  are  indefinite  until 
enlargement  of  the  abdomen  is  noticed.  There  may  have  been  some 
vomiting  and  slight  abdominal  pain,  and  bowel  disturbance ;  but 
the  permanent  enlargement,  and  the  presence  of  fluid  characterize 
the  disease  as  more  than  an  ordinary  digestive  ailment.  The  ab- 
domen becomes  filled  with  the  fluid.  This  may  easily  be  demon- 
strated by  the  percussion  wave.  When  the  patient  is  placed  in  the 
dorsal  decubitus  the  fluid  gravitates  into  the  flanks,  where  it  gives 
a  dull  percussion  note,  while  the  intestines,  floating  near  the  umbili- 
cus, are  tympanitic.  The  distension  may  gradually  increase  to  such 
a  degree  that  the  entire  dome-shaped  abdomen  is  dull,  the  skin  is 
tense  and  shining,  with  large  blue  veins  showing  on  the  surface  and 
the  protruding  umbilicus  filled  with  fluid.  Or  the  effusion  may  be 
sacculated  by  adhesions.  The  distension  precludes  the  palpation  of 
enlarged  mesenteric  nodes  in  most  cases,  and  often  makes  it  difficult 
to  define  the  size  of  the  liver.  Hepatitis  or  perihepatitis  may  be 
present,  but  cirrhosis  of  the  liver  may  generally  be  excluded  in  a 
young  child,  is  much  more  chronic  in  its  course,  and  usually  pre- 
sents jaundice.  If  evidence  of  syphilis  can  be  obtained,  cirrhosis  is 
rendered  probable.  Some  of  the  fluid  may  be  withdrawn  and  ex- 
amined for  bacilli  or  injected  into  guinea-pigs  or  rabbits.  Ordinarily 
there  is  no  great  difficulty  in  diagnosis,  yet  a  case  may  be  so  compli- 
cated as  to  be  very  obscure,  as  illustrated  by  the  following  in  a  boy 
of  three  years.  It  was  said  that  a  year  previously  he  had  passed 
through  measles,  which  left  him  with  a  chronic  cough.  Eight 
months  after  the  measles  the  abdomen  was  noticed  to  be  enlarging. 
When  first  examined  in  my  clinic  at  the  College^  of  Physicians  and 
Surgeons,  the  abdomen  was  so  tensely  filled  with  fluid  that  the  liver 
could  not  be  outlined.  Breathing  was  difficult,  cough  almost  con- 
stant ;  the  loud  mucous  rales  and  the  rapid  action  of  the  heart  ob- 
scured its  sounds,  no  valvular  murmur  being  detected.  The  area 
of  cardiac  dullness  was  increased.     He  was  tapped  and  eight  and 


558  SURGICAL   DISEASES    OF    CHILDREN 

one-half  pints  of  fluid  were  withdrawn,  enough  to  reheve  the  tension. 
The  fluid  was  yellow  with  greenish  tinge.  On  examination  by  Dr. 
R.  G.  Schnee,  it  presented  the  characteristics  of  ascitic  fluid,  and 
no  bacilli  were  found.  After  tapping  the  liver  could  be  outlined. 
Fig.  190  shows  the  lower  margin  of  the  liver  marked  by  the  dark 
line.  Spleen  not  palpable.  The  stools  were  light  colored,  but  showed 
some  bile.  The  blood  examination  showed  no  leukemia.  The 
symmetrical  shape  of  the  liver  and  the  length  of  time  elapsed  elimi- 
nated endothelioma.  Reaction  from  tuberculin  (subcutaneously) 
was  positive.  There  was  low  fever  and  wasting.  A  diagnosis  of 
tubercular  peritonitis  was  made  and  laparotomy  or  repeated  tap- 
ping proposed,  but  the  parents  refused.  He  lived  more  than  two 
months.  At  autopsy,  a  few  tubercles  were  found  upon  peritoneum 
and  mesentery,  and  a  number  of  mesenteric  and  bronchial  glands 
were  cheesy.  The  important  lesion  was  an  adhesive  pericarditis,  to 
which  more  than  to  the  tuberculosis,  the  condition  of  the  respiration 
and  hepatic  enlargement  and  ascites  were  attributable. 

Prognosis. — The  prognosis  is  guarded.  Most  cases  terminate 
in  death  by  exhaustion.  But  it  is  not  so  very  unusual  to  have  a  case 
recover,  by  reabsorption  of  the  fluid,  and  a  process  of  fibrosis.  Or 
the  lesions  may  break  down  and  after  forming  many  ulcerations  and 
adhesions,  terminate  fatally  by  exhaustion,  or  by  general  or  other 
local  tuberculosis. 

The  Fibro-plastic  Form. — There  is  usually  serous  effusion  in 
this  variety,  but  if  so  it  is  not  as  early  or  as  marked  a  feature.  This 
inflammation  produces  a  plastic  exudate  which  forms  adhesions 
that  become  fibrous,  joining  intestines  together,  or  to  abdominal 
walls  or  to  the  viscera ;  or  unites  any  of  the  serous  surfaces  in  the 
abdomen  that  lie  adjacent  to  each  other.  When  ascitic  fluid  or  pus 
is  formed  it  is  sacculated  between  adhesions.  The  disease  begins 
insidiously  with  symptoms  usually  attributed  to  digestive  disturb- 
ance, but  there  may  be  persistent  low  fever.  Often  nothing  local 
is  observed  until  the  abdomen  enlarges.  The  enlargement  may  be 
due  to  tympanites  at  first,  but  later  to  fluid.  And  it  may  be  irregular 
in  shape  on  account  of  the  binding  of  adhesions,  and  fibrinous  bands, 
which,  if  the  walls  are  not  too  tense,  can  be  felt  as  irregular  masses 
in  the  abdomen.  The  disease  runs  a  very  chronic  and  irregular 
course,  both  as  regards  the  symptoms  of  indigestion  and  loss  of 
weight;  and  in  respect  to  the  enlargement  of  the  abdomen,  which 
may  subside  somewhat  and  increase  again  or  change  its  position. 
Fever  is  of  the  hectic  type  and  may  register  i,  2,  or  3  degrees. 
There  may  be  pain  and  interference  with  peristalsis,  or  with  blood 
or  lymph  circulation  from  the  constriction  of  adhesions.  There  is 
nothing  characteristic  about  the  bowel  movements.  Diarrhea  is  not 
present  unless  there  is  ulceration  of  the  intestinal  mucous  lining, 


THE  ABDOMEN,  ITS   MALFORMATIONS   AND  DISEASES      559 

which  is  not  as  common  a  symptom  as  some  suppose.  There  is  not 
uncommonly  edema  of  the  lower  extremities,  in  odd  contrast  with 
the  general  emaciation.  This  is  produced  by  pressure  on  the  ascend- 
ing" vena  cava.  Albuminuria  may  result  from  interference  with  the 
renal  circulation.  Most  cases  extend  over  a  period  of  several  months 
or  a  year  and  end  fatally  by  exhaustion  or  perhaps  by  lung  tubercu- 
losis, or  with  lardaceous  liver,  kidneys,  and  spleen.  An  occasional 
case  will  improve  after  three  or  four  months  and  make  an  apparent 
recovery. 

The  Ulcerative  Form. — In  this  form,  as  its  name  implies,  the 
tendency  of  the  inflammation  is  toward  ulceration.  Fibro-plastic 
exudation  takes  place  and  abundant  tuberculous  deposits  are  formed, 
but  these  undergo  cheesy  degeneration  and  break  down,  forming 
tuberculous  abscesses.  In  this  form  the  abdominal  walls  and  the 
intestines  themselves  are  more  apt  to  be  inflamed  and  to  contain 
abscesses,  ulcers,  and  sinuses.  Distinct  masses  and  nodules  may 
usually  be  felt.  The  general  condition  is  more  typical  of  tuberculosis 
than  usually  obtains  with  the  other  forms  of  tubercular  peritonitis. 
Hectic  is  present  and  wasting  is  progressive.  Almost  invariably 
there  is  tuberculosis  of  other  organs  or  regions,  although  it  may 
be  hard  to  demonstrate  during  life.  Recovery  from  the  ulcerative 
form  need  not  be  expected. 

Diagnosis. — Concerning  the  diagnosis  of  all  the  forms  of  tuber- 
cular peritonitis  it  may  be  said  that  chronic  ascites  in  a  child  from 
any  other  cause  is  very  uncommon ;  and  that  if  it  is  accompanied 
by  hectic  fever  it  is  almost  certainly  tuberculous.  If  nodosities,  such 
as  enlarged  mesenteric  nodes,  can  be  felt,  or  irregularities  caused  by 
adhesions  or  encysted  collections  of  fluids  in  various  parts  of  the 
abdomen ;  or  if  there  is  evidence  of  tuberculosis  in  other  parts  of  the 
body  with  chronic  abdominal  enlargement  and  ascites,  tubercular 
peritonitis  may  be  presumed.  Family  history,  if  negative,  does  little 
to  exclude  it.  Pain  and  tenderness  are  of  uncertain  value.  The 
tuberculin  test  is  of  value  for  demonstrating  the  presence  of  tuber- 
culosis in  the  system,  but  does  nothing  in  regard  to  localizing  it. 
Tapping  is  useful  for  diagnosis,  if  the  bacilli  can  be  found  in  the 
fluid,  but  their  absence  does  not  absolutely  disprove  the  disease. 
Inoculation  experiments  are  valuable.  Tapping  may  also  make  pal- 
pation of  the  abdominal  contents  possible.  Exploratory  incision  is 
justifiable,  and  if  made,  any  enlarged  lymphatic  gland  encountered 
should  be  removed  for  miscroscopic  examination  and  inoculation 
test. 

Treatment. — The  general  treatment  of  tuberculosis  should  be 
instituted  and  thoroughly  and  persistently  carried  out.  Purgation 
or  other  irritation  of  the  intestines  should  be  avoided,  but  they  should 
be  regulated  by  diet,  enemata,  and,  if  necessary,  by  gentle  laxatives. 


56o  SURGICAL   DISEASES    OF   CHILDREN 

It  is  doubtful  if  much  may  be  accomplished  by  local  applications  to 
control  a  tubercular  process.  Yet  the  inflammation  may  be  modi- 
fied and  perhaps  the  invasion  of  other  infective  agents  prevented  by 
drugs.  The  use  of  ointment  of  the  yellow  oxide  of  mercury,  20 
grains  to  the  ounce,  with  an  equal  quantity  of  the  unguentum  bella- 
donnse  is  recommended  by  Ashby  and  Wright.  I  have  used  the 
ordinary  mercurial  ointment,  diluted  with  lanolin,  with  apparent 
benefit.  Of  more  positive  utility  in  this  disease,  though  used  only 
for  the  symptoms  of  pain  and  tenderness,  is  the  extract  of  bella- 
donna (solid)  with  glycerine,  one  drachm  to  the  ounce.  After 
cleansing  the  skin  with  soap  and  water  and  with  alcohol,  this  should 
be  smeared  upon  it  and  then  covered  with  oil  silk. 

If  life  in  the  open  air,  rest,  forced  feeding,  general  hygienic 
management  and  medication  do  not  produce  the  desired  result, 
operative  treatment  is  indicated  in  selected  cases.  It  is  not  advisable 
to  operate  in  the  acute  miliary  nor  in  the  ulcerative  forms  of  the 
disease,  nor  in  the  so-called  "  dry  "  form,  which  is  a  variety  of  the 
fibro-plastic  without  ascites,  nor  in  general  tuberculosis  that  is  rapidly 
progressive,  nor  in  the  presence  of  meningeal,  or  serious  lung  tuber- 
culosis. If  either  tubercular  ulceration  of  the  intestines  or  tuber- 
cular nephritis  be  present,  operation  will  be  unavailing.  All  cases 
in  which  diagnosis  has  been  impossible  should  be  operated  for  ex- 
ploration. 

The  second  form  described,  that  is,  the  ascitic,  is  the  most 
favorable  for  operation.  In  the  fibro-plastic  form  a  natural  effort 
at  cure  is  in  progress  and  need  not  be  interfered  with  unless  there 
is  also  ascites,  or  fibrous  bands  cause  obstipation  or  painful  tympa- 
nites, or  a  fluid  collection  even  though  small  is  purulent,  or  the 
patient  is  losing  health  and  strength.  In  obstruction  of  the  bowels 
or  in  severe  pain  which  is  exhausting  the  patient,  there  is  no  choice 
but  to  operate. 

The  operative  treatment  Is  simple  laparotomy,  with  evacuation 
of  fluid  collections  with  or  without  irrigation ;  and  either  immediate 
closure  or  drainage.  The  patient  should  be  prepared  by  thorough 
clearing  of  the  intestinal  tract,  by  castor-oil  and  by  the  use  of  anti- 
fermentative  drugs  such  as  salol,  benzosol,  calomel.  The  skin  of  the 
abdomen  should  be  prepared  in  the  usual  careful  manner  for  an 
abdominal  section.  If  the  case  is  one  of  the  ascitic  variety  an  in- 
cision is  made  in  the  linea-alba  below  the  umbilicus,  remembering 
that  the  bladder  rises  higher  in  the  child  than  in  the  adult,  and  the 
younger  the  child  the  higher  the  bladder  is  likely  to  be  located.  The 
peritoneum  should  be  opened  with  the  usual  care  after  raising  it 
between  two  pairs  of  forceps,  and  incised  at  least  to  the  width  of 
two  fingers.  The  next  step  will  depend  upon  the  conditions.  If  the 
fluid  is  free  in  the  peritoneal  cavity,  all  that  is  necessary  is  tg  allow 


THE  ABDOMEN,  ITS   MALFORMATIONS  AND   DISEASES      561 

it  to  flow  out  and  then  close  the  incision.  If  sacs  of  fluid  can  be 
detected  here  and  there,  held  by  adhesions,  they  should  be  reached 
and  evacuated.  Otherwise  the  adhesions  should  be  disturbed  as  little 
as  possible.  Some  operators  advise  the  removal  of  the  omentum,  if 
it  be  loaded  with  tubercles,  but  this  is  not  advisable  unless  large 
masses  appear  about  to  soften.  Its  removal  will  prove  more  trou- 
blesome than  might  be  anticipated  on  account  of  hemorrhage. 

If,  on  the  other  hand,  the  fluid  prove  to  be  purulent,  it  is  better  to 
irrigate  the  abdomen  either  with  sterile  normal  salt  solution,  flowing 
gently  but  freely  through  the  nozzle  of  the  irrigator  at  a  temperature 
of  105  degrees  F.  Some  would  advise  a  solution  of  boracic  acid, 
salicylic  acid,  or  argyrol,  which  are  all  good.  If  there  is  a  locaHzed 
purulent  collection  in  some  part  of  the  abdomen,  the  incision  is  made 
there  instead  of  in  the  median  line  and  the  adhesions  separated  until 
the  abscess  is  found,  which  may  be  a  little  troublesome  to  do.  After 
evacuation  the  cavity  is  irrigated  as  before  described.  The  non- 
purulent cases  are  closed  without  drainage ;  in  the  purulent  a  drain- 
age tube  or  cigarette  drain  of  rolled  rubber  tissue,  or  a  flexible  rub- 
ber-tissue tube  with  a  wick  of  iodoform  gauze,  or  simply  the  gauze 
wick  drain  may  be  used.  The  peritoneum  is  closed  with  continuous 
suture  of  catgut,  the  muscular  wall  with  catgut  or  kangaroo  ten- 
don, and  the  skin  with  silkworm  gut.  A  few  operators  use  silver 
wire  through  the  skin  and  muscular  layer,  with  coaptation  stitches 
of  silkworm  gut  or  horsehair  between.  In  the  drained  cases  the 
drainage  is  removed  as  soon  as  possible,  usually  in  a  few  days  or  a 
week,  and  the  track  closes  by  granulation.  The  usual  dressings  of 
antiseptic  gauze,  cotton,  adhesive  strapping  and  binder  are  em- 
ployed. 

The  rationale  of  this  method  of  treatment  is  not  well  understood, 
or  at  least  has  no  explanation  that  is  generally  accepted.  It  is  an 
empirical  method,  often  permanently  successful.  If  relapse  occurs 
the  laparotomy  may  be  repeated.  (45) 


CHAPTER  XXI 

THE    ESOPHAGUS,    STOMACH    AND 
INTESTINES 

Malformation  of  the  Esophagus — Foreign  Body  in  Esophagus 
— Stricture  of  the  Esophagus — Pyloric  Stenosis — Mal- 
formations of  the  Small  Intestines  and  Colon — Intus- 
susception— Foreign  Body  in  Stomach,  Intestine  or 
Rectum — Fecal  Impaction — Enterolites — Volvulus — In- 
ternal Strangulation. 

MALFORMATION    OF    THE    ESOPHAGUS 

The  esophagus  develops  independently  of  the  pharynx  and  the 
stomach,  both  of  which  it  opens  into  as  its  tube  lengthens.  Mal- 
formation may  occur  by  failure  of  the  esophagus  to  penetrate  into 
the  stomach  below  or  less  frequently  into  the  stomadseum  above. 
I  have  twice  met  malformation  near  the  point  where  pharynx  and 
esophagus  join,  which  resulted  in  death.  In  one  case,  seen  with 
Dr.  H.  T.  Clapp,  the  esophagus  and  the  larynx  were  connected 
by  a  slit-like  orifice.  In  the  other,  seen  with  Dr.  G.  U.  Bennett,  the 
pharynx  ended  in  a  blind  cul-de-sac  behind  the  larynx,  the  esophagus 
having  failed  to  reach  and  penetrate  it.  In  some  cases  the  con- 
nection between  pharynx  and  esophagus  is  imperfect,  leaving  a 
partial  stenosis. 

FOREIGN   BODY   IN   ESOPHAGUS 

Most  foreign  bodies  swallowed  by  children  pass  into  the 
stomach,  and  their  further  adventures  will  be  considered  in  another 
section.  But  every  child  supposed  to  have  swallowed  a  foreign  body 
should  be  examined.  The  symptoms  will  vary  with  the  size  and 
shape,  position  and  substance  of  the  foreign  body.  If  a  round, 
bulky  body,  like  a  marble,  be  lodged  in  the  esophagus,  there  will 
be  an  obstruction  to  drink  or  food  swallowed,  and  they  will  be 
regurgitated.  A  coin  may  allow  them  to  pass ;  or  may  change  its 
position  so  that  neither  food  nor  drink  can  pass.  A  substance  that 
will  swell  by  absorbing  moisture  may  not  cause  obstruction  at  first, 
but  later.  A  body  not  tightly  wedged  in  the  esophagus,  nor  en- 
tirely blocking  it,  may  cause  few  symptoms  and  be  overlooked  at 

562 


ESOPHAGUS,    STOMACH    AND    INTESTINES  563 

first,  but  later  inflammation  rises  and  it  becomes  embedded,  and 
ulceration,  and  probably  extensive  cellulitis,  suppuration,  pneumonia, 
and  exhaustion  follow. 

Treatment. — If  a  body  be  lodged  just  below  the  gullet  it  may 
perhaps  be  seen  by  direct  inspection,  extending  the  head  fully  and 
using  a  tongue  depressor  well  back.  Or  it  may  be  touched,  and  pos- 
sibly dislodged,  with  the  index  finger.  If  it  be  lodged  lower  Its  situa- 
tion may  sometimes  be  detected  by  listening  at  the  chest  while  the 
child  swallows  a  drink  of  water.  In  this  class  of  cases  the  gastro- 
scope,  as  devised  and  used  by  Jackson,  of  Pittsburg,  is  destined  to 
fill  an  important  place.  Jackson  has  explored  not  only  the  esopha- 
gus, but  the  stomach  of  a  babe  not  older  than  one  year  and  two  days. 
In  the  absence  of  special  instruments  and  skill  in  their  use,  the 
bristle  probang  may  be  employed  to  either  push  the  body  on  into 
the  stomach  or  to  withdraw  it.  The  bristles  of  the  instrument  hav- 
ing been  passed  below  the  obstruction  and  spread  into  disc  form 
by  proper  manipulation,  the  body  may  be  swept  upward  as  the 
instrument  is  withdrawn.  The  ingenious  coin-catchers  of  the  instru- 
ment makers  occasionally  work  as  they  are  intended,  and  as  often 
do  not.  Emetics  should  not  be  used.  Forceps  are  useful  if  the  body 
is  of  suitable  shape  to  be  seized,  is  within  reach,  and  the  surgeon 
dextrous.  Inversion  of  the  patient  and  bimanual  manipulation  may 
be  useful. 

Failing  in  these  endeavors,  esophagatomy  must  be  done,  and 
that  promptly.  If  done  before  inflammation  and  fever  supervene, 
there  is  a  good  prospect  of  recovery.  The  impaction  unrelieved 
will  cause  death.  The  operation  is  done  as  in  the  adult,  upon  the 
left  side,  and  is  difficult  in  proportion  as  the  child  is  short-necked 
and  fat.  The  external  incision  should  be  ample,  in  order  that  hem- 
orrhage in  the  depth  may  be  controlled,  or,  better,  avoided  by  seiz- 
ing vessels  before  they  are  cut.  The  recurrent  laryngeal  nerve, 
which  passes  between  the  esophagus  and  the  trachea,  should  be 
avoided.  The  esophagus  can  be  pushed  into  the  wound  by  a  curved 
sound  passed  per  orem,  and  opened  with  scissors.  The  foreign  body 
should  then  be  removed  with  forceps.  The  esophagus  is  closed  with 
Lembert  sutures,  unless  it  is  badly  inflamed,  and  the  external  wound 
closed  with  drainage.  The  patient  is  fed  per  rectum  for  several 
days,  when  stomach  feeding  by  tube  can  be  used.  (See  Section  on 
Gavage.) 

STRICTURE    OF    THE    ESOPHAGUS 

Stricture  of  the  esophagus,  from  malformation  has  been 
alluded  to  in  another  section.  A  more  common  form  is  caused  by 
cicatrices,  following  burns  from  swallowing  corrosive  substances, 
such  as  concentrated  lye  or  ammonia,  or  from  scalding. 


564  SURGICAL  DISEASES  OF  CHILDREN 

Symptoms. — Symptoms  may  not  appear  until  several  weeks 
after  the  accident.  The  stenosis  causes  difficulty  of  swallowing 
and  regurgitation,  and  in  the  absence  of  history  might  even  be 
mistaken  for  foreign  body.  The  child  it  often  weak  and  emaciated 
from  starvation. 

Treatment. — Treatment  with  bougies,  dilating  the  stricture, 
and  gavage  and  rectal  feeding  improve  most  cases  and  cure  some. 
The  trouble  is  apt  to  recur  and  require  persistent  and  careful  atten- 
tion. Some  cases  ultimately  sink,  on  account  of  extensive  damage 
of  the  stomach  mucosa. 

PYLORIC  STENOSIS 

Pyloric  stenosis  may  be  described  as  of  four  kinds,  differing 
widely  as  to  pathology.  First,  congenital  stenosis  of  the  pylorus ; 
secondly,  hypertrophic  stenosis,  or  congenital  hypertrophic  stenosis; 
thirdly,  spasmodic  constriction,  or  spasm  of  the  pylorus.  The 
second  and  third  kinds  are  the  ones  rnost  often  described  under  the 
title  "  pyloric  stenosis  of  infants  "  and  divided  into  two  varieties, 
hypertrophic  an  spasmodic.  Fourthly  we  have  pyloric  stenosis  of 
older  children. 

Etiology  and  pathology. — Congenital  stenosis,  not  marked  by 
hypertrophy,  occurs  in  rare  instances  at  the  pylorus  as  it  does  in 
other  regions  of  the  gastro-intestinal  tract  (notably  at  the  site  of  the 
common  bile-duct  and  in  the  ileum),  the  narrowing  varying  in  de- 
gree even  to  atresia.  It  is  a  developmental  failure,  obscure  in  its 
ultimate  etiology.  The  malformation  is  usually  not  confined  to  the 
pylorus. 

Hypertrophic  pyloric  stenosis  has  been  much  discussed  not 
only  as  to  its  etiology  and  pathology  but  as  to  its  entity.  Its  entity 
is  established.  (Hirschsprung,  Cautley  and  Dent,  Ibrahim.)  It  is 
not  the  same  as  spasmodic  stenosis,  although  there  is  no  denying 
that  it  may  be  accompanied  by  spasm.  And  it  is  true  that  either 
hypertrophic  or  spasmodic  stenosis  may  show  redundance  or  catar- 
rhal conditions  of  the  mucous  lining  which  aggravate  the  effects. 
Skillful  feeders  like  Huebner  are  able  to  avoid  or  relieve  many  ag- 
gravated conditions,  and  in  the  mild  grades  of  stenosis  escape  the 
fatal  closure.  But  it  cannot  be  concluded  therefore  that  an  organic 
stenosis  never  exists.  Nor  has  Pfaundler's  argument  (that  spasm 
of  the  pylorus  persisting  even  after  death,  can  produce  a  tumor  re- 
sembling hypertrophic  stenosis),  been  accepted  as  explaining  away 
the  organic  tumor  found  by  many  other  observers  both  before  and 
after  death,  and  before  and  after  operation  had  removed  all  the 
other  symptoms.  This  tumor  is  of  the  size  of  a  hazelnut  or  a  filbert, 
and  the  microscope  reveals  that  its  bulk  is  made  up  by  an  increase 
in  the  muscular  fibres  of  the  pylorus,  the  greater  part  of  it  being 


ESOPHAGUS,  STOMACH  AND  INTESTINES  565 

due  to  hypertrophy  of  the  circular  muscular  fibres.  There  is  also 
increased  connective  tissue  and  redundance  of  mucous  membrane, 
with  narrowing  of  the  lumen  of  the  canal.  When  and  how  this 
hypertrophy  takes  place  have  been  much  disputed.  One  of  the 
principal  theories  attributes  it  to  faulty  embryological  development. 
And  this  condition  has  been  found  in  various  stages  of  fetal  life. 
Another  theory  considers  the  increase  of  tissue  a  true  hypertrophy, 
induced  by  spasmodic  overaction  of  the  muscle.  The  obvious  ob- 
jectiorts  to  this  view  are  well  presented  by  Cautley  who  points  out 
that  spasm  of  the  pylorus  is  not  a  disorder  peculiar  to  the  first  few 
months  of  life.  It  may  occur  at  any  age.  But  there  is  no  evidence 
to  show  that  spasm  produces  hypertrophy  at  any  other  age,  nor  any 
reason  why  it  should  do  so  in  infancy  and  not  do  so  later.  Cases 
of  pyloric  spasm  have  persisted  to  a  fatal  termination  without  pro- 
ducing hypertrophy.  There  is  no  analogous  instance  of  hypertrophy 
produced  by  spasm  in  any  other  portion  of  the  alimentary  canal ; 
for  instance,  anal  spasm  is  common,  but  does  not  produce  hyper- 
trophy. If  the  hypertrophy  is  produced  by  spasm  the  longitudinal 
fibres  should  be  increased  in  proportion  to  the  circular.  But  this  is 
not  found  to  be  true.  Furthermore  if  the  hypertrophy  were  due  to 
spasm  it  should  disappear  after  operation,  the  cause  of  the  spasm 
and  the  other  symptoms  having  been  removed.  But  it  has  been 
demonstrated  that  the  tumor  persists  after  operation.  (Scudder  and 
others.) 

In  the  present  state  of  knowledge  it  is  more  reasonable  to  be- 
lieve that  the  hypertrophy  is  present  at  birth  and  may  show  at  once ; 
but  that  when  the  narrowing  is  only  of  a  mild  degree  it  gives  no 
symptoms  until  some  irritation  (such  as  indigestion  or  hyperacidity) 
produces  spasm,  and  this  (aided  probably  by  a  catarrhal  thickening 
of  the  mucosa)  sets  up  the  obstruction.  A  high  situation  of  the 
pylorus  and  consequent  angulation  also  figure  as  possible  etiological 
factors.  Hereditary  history  of  stomach  troubles  and  neuroses  bear 
an  uncertain  relationship  to  pyloric  stenosis. 

Spasm  of  the  pylorus  is  an  affection  distinct  from  hypertrophic 
stenosis  but  showing  no  appreciable  pathological  anatomy.  It  oc- 
curs most  often  in  infants  of  excitable  or  "  nervous  "  type.  Be- 
yond this  there  is  nothing  definitely  causative.  Its  nature  will  be 
further  brought  out  in  the  symptomatology  and  diagnosis. 

Pyloric  stenosis  of  older  children  may  be  produced  by  causes 
acting  from  within,  such  as  contraction  of  scars  resulting  from  cor- 
rosive poison,  from  ulceration,  or  from  a  wound  produced  by  a 
foreign  body;  or  by  plugging  of  the  pylorus  by  a  polypoid  tumor. 
That  common  cause  of  pyloric  obstruction  in  adults — carcinoma — is 
a  possibility  though  extraordinarily  rare  in  children.     Or  the  cause 


566  SURGICAL  DISEASES  OF  CHILDREN 

may  act  from  without,  as  in  constriction  by  bands  or  adhesions, 
pressure  of  a  tumor,  displacement  of  the  stomach  with  angulation 
of  the  pylorus.  There  is  a  possibility  that  hypertrophic  stenosis  may 
persist  to  a  degree  into  childhood  or  even  later  life. 

Symptoms  and  diagnosis. — The  symptoms  of  congenital  stenosis 
are  those  of  obstruction  more  or  less  complete.  They  are  present 
from  birth  or  at  least  from  the  earliest  taking  of  food.  The 
symptoms  of  hypertrophic  stenosis  and  of  spasm  of  the  pylorus  may 
be  considered  together.  They  are  very  similar,  differing  only  in 
severity  and  mode  of  appearance.  The  clinical  picture  of  spasm  is 
familiar  to  all  pediatrists,  but  sliould  be  distinguished  from  chronic 
gastric  indigestion  and  habitual  vomiting.  Morse  ^  states  the 
symptoms  well  and  briefly.  The  condition  occurs  most  frequently 
in  babies  of  the  excitable,  neurotic  type,  whether  breast-fed  or  bot- 
tle-fed, but  more  often  in  the  latter  class.  As  a  rule  the  symptoms 
do  not  begin  immediately  after  birth,  but  develop  in  the  first  few 
weeks  or  months.  The  severity  of  the  symptoms  varies  greatly  in 
different  cases  according  to  the  degree  of  spasm.  The  milder  case 
is  characterized  by  frequent  vomiting  which  may  or  may  not  be  ex- 
plosive, and  is  usually  accompanied  by  gastric  pain  and  distress. 
The  vomitus  does  not  give  marked  evidence  of  indigestion,  and  in 
quantity  amounts  to  no  more  than  was  taken  at  the  last  meal.  In- 
digestion and  hyperacidity,  when  present,  favor  a  diagnosis  of 
spasm  rather  than  hypertrophic  stenosis.  While  defecation  is  in- 
frequent there  is  some  stool,  showing  that  a  considerable  amount 
of  food  does  pass  through  the  pylorus  and  intestines.  Nutrition  is 
not  greatly  disturbed.  In  the  severe  case,  to  these  symptoms  is 
added  that  of  gastric  peristalsis,  and  the  stools  are  smaller  and  the 
disturbance  of  nutrition  is  greater.  There  may  be  a  palpable  small 
tumor  at  the  pylorus  in  spasm. 

The  symptoms  of  hypertrophic  stenosis  are  very  similar  to 
those  of  spasm.  They  commence  from  a  few  days  to  several  weeks 
after  birth.  There  is  vomiting,  which  is  apt  to  be  explosive  and 
forcible.  It  may  be  irregular  at  first,  but  tends  to  become  more 
regular,  following  feeding,  and  to  be  persistent.  There  is  pain 
and  distress.  The  quantity  of  vomitus  may  indicate  that  some  in- 
gesta  have  been  retained  from  feedings  previous  to  the  last.  The 
vomitus  is  neither  sour  nor  bile-stained.  With  all  the  vomiting  the 
baby  is  eager  for  more  food.  Infrequent  and  scanty  stools  and 
loss  of  weight  are  quite  marked.  On  inspection  the  abdomen  ap- 
pears pear-shaped,  being  distended  above  in  the  stomach  region,  and 
small  in  the  region  of  the  empty  intestines — an  exaggeration  of  the 
infant  type  of  abdomen.     Distinct  dilatation  of  the  stomach  is  rare 

^Am.  Jour,  Dis.  Child.,  May,  191 1. 


ESOPHAGUS,  STOMACH  AND  INTESTINES  567 

in  pyloric  spasm,  and  although  not  invariably  present  in  hypertrophic 
stenosis,  when  found  it  favors  a  diagnosis  of  the  latter  condition. 
In  hypertrophy  visible  gastric  peristalsis  is  exaggerated.  Distinct 
waves  of  contraction  pass  from  left  to  right  across  the  stomach 
region,  beginning  in  the  left  hypochondrium  and  traveling  to  the 
pyloric  end.  These  waves  of  course  are  not  at  all  times  visible. 
They  are  best  seen  after  the  babe  has  taken  some  food  or  drink,  or 
may  sometimes  be  excited  by  percussion  or  massage  over  the 
stomach.  Tumor  may  be  felt  at  the  pylorus  about  the  level  of  the 
first  lumbar  vertebra,  to  the  right  of  the  median  line.  The  char- 
acteristic tumor  is  larger  than  in  spasm,  its  size  approximating  that 
of  a  filbert,  and  it  does  not  change  so  markedly  in  size  and  firmness 
during  examination  as  'in  spasm.  Tumor,  although  present,  may 
not  be  palpable  at  all  until  operation ;  or  may  be  found  only  by  very 
careful  search,  which  if  .necessary,  should  be  made  under  various 
conditions,  both  after  feeding  and  after  the  stomach  is  emptied  by 
vomiting,  and  when  the  abdominal  walls  are  relaxed  by  a  few  drops 
of  chloroform.  The  finding  of  the  firm  palpable  tumor,  in  the 
case  of  persistent  Vomiting  and  wasting  which  resists  proper  feed- 
ing and  medical  treatment,  justifies  a  diagnosis  of  hypertrophic 
stenosis. 

The  symptoms  of  pyloric  stenosis  of  older  children  have  usually 
been  preceded  by  a  history  of  the  swallowing  of  caustic  or  of  a 
sharp  foreign  body,  or  of  the  presence  of  ulcer,  or  of  a  peritonitis 
capable  of  producing  adhesions ;  or  a  tumor  may  be  found  in  the 
region.  Obstruction  produces  pain  and  distress,  vomiting,  wasting, 
absence  of  stool  and  sometimes  dilatation  of  the  stomach.  The 
X-rays,  after  ingestion  of  bismuth,  are  a  very  valuable  means  in 
the  hands  of  a  skillful  radiographer  and  interpreter  of  radio- 
graphs, in  determining  malpositions,  contractions,  adhesions,  scars, 
ulcerations,  dilatations  and  malpositions  of  the  stomach  and  py- 
lorus. 

Treatment. — The  treatment  of  congenital  stenosis,  briefly  stated, 
consists  in  short-circuiting  around  the  stenosis,  unless  accompany- 
ing malformations  render  this  impracticable. 

The  treatment  of  pyloric  spasm  is  directed  toward  feeding 
without  irritation  of  the  stomach,  allaying  spasm  by  drugs  and  by 
warmth  over  the  abdomen,  avoiding  all  general  excitement;  and 
keeping  the  babe  completely  at  rest  after  feeding.  Sometimes  gas- 
tric lavage  is  useful.  A  few  hints  on  food  and  drugs  will  be  found 
in  the  Appendix  (46). 

If  a  faithful  trial  of  medical  means  fails  to  bring  success,  opera- 
tion should  be  performed  the  same  as  in  hypertrophic  stenosis.  For 
it  is  well  established  that  spasm  without  hypertrophy  may  cause  a 
fatal  ending. 


568  SURGICAL  DISEL'^SES  OF  CHILDREN 

The  treatment  of  hypertrophic  stenosis  is  surgical  in  all  cases 
in  which  the  narrowing  exists  to  such  a  degree  that  the  little  patient, 
although  properly  fed  and  cared  for,  cannot  maintain  his  nutrition 
and  advance  in  weight,  strength,  and  development.  As  soon  as  this 
condition  of  things  has  been  demonstrated,  no  time  should  be  lost  in 
waiting  and  hoping.  Delay  only  lessens  his  chances  of  life  which 
are  good  if  operation  is  resorted  to  before  wasting  and  weakness 
are  extreme.  Without  operation  they  are  nil.  One  has  the  choice 
of  stretching  the  pylorus  and  of  several  plastic  operations.  (For 
brief  remarks  on  some  of  these  see  Appendix  46.) 

Gastro-enterostomy  is  the  one  operation  which  is  generally 
technically  practicable  and  secures  an  adequate  and  permanent 
opening  between  stomach  and  small  intestines.  It  interferes  little 
if  any  with  the  metabolism  of  ingesta  as  shown  by  subsequent 
analyses  of  stomach  contents  and  excreta,  and  by  the  condition  of 
the  patients  who  survive.  The  mortality  at  present  is  about  fifty 
per  cent.  This  will  be  greatly  reduced  when  operation  is  resorted 
to  as  early  as  it  should  be.  Various  forms  of  gastro-enteric  anas- 
tomosis have  been  tried,  and  we  are  indebted  to  many  different  men, 
probably  to  none  more  than  Scudder  of  Boston,  for  study  of  the 
subject  and  improvement  in  the  technique.  Undoubtedly  the  best 
operation  is  posterior  gastro-jejunostomy.  Strict  aseptic  prepara- 
tion is  necessary,  but  no  exposure  for  washing  at  the  time  of  the 
operation.  If  the  umbilicus  has  been  inflamed  it  should  after 
thorough  cleansing  be  sealed  up.  The  patient's  extremities  are 
swathed  in  cotton  wool.  Not  only  should  the  room  be  warm,  but  the 
table  should  be  warmed  and  kept  warm.  The  stomach  should  be 
empty  or  be  washed  out  before  the  operation.  The  present  fashion 
favors  ether  as  the  anesthetic,  but  whatever  anesthetic  is  used  the 
anesthetist  should  be  one  thoroughly  skilled  and  watchful,  and 
oxygen  should  be  used  in  conjunction  upon  the  slightest  indication. 
Very  small  instruments,  such  as  clamps  and  forceps  should  be  used. 
The  median  incision,  small  at  first  for  examination,  may  be  carried 
somewhat  low,  going  to  the  left  of  the  umbilicus.  If  possible,  the 
stomach  and  intestines  are  not  to  be  delivered  from  the  abdomen. 
The  wound  can  be  pulled  to  the  left  enough  to  come  at  the  stomach. 
The  colon  being  raised,  the  jejunum  is  thereby  lifted  into  view  and 
should  be  taken,  and  not  other  bowel  used  instead.  Clamps  are  use- 
ful. If  the  stomach  is  dilated  with  gas,  a  catheter  is  passed  by  the 
esophagus  to  collapse  it;  or  the  work  can  be  done  without  clamps. 
The  Murphy  button  (or  similar  devices)  is  not  available  in  these 
small  patients.  The  Lembert  line  is  made  with  fine  linen  thread. 
Some  use  silk.  The  incision  for  the  stoma  is  an  inch  long.  The 
inside  stitching  is  done  with  zero  chromacized  gut.     The  anasto- 


ESOPHAGUS,  STOMACH  AND  INTESTINES  569 

mosis  completed,  a  catheter  may  be  passed  (per  orem)  through 
it,  and  a  dose  of  water  placed  in  the  intestines  before  closing  the 
abdomen,^  or  a  hypodermic  of  camphor-oil,  or  saline  solution  subcu- 
taneously  or  per  rectum  should  be  used.  The  after-care  is  impor- 
tant. He  is  removed  to  a  warm  bed,  and  after  recovery  from 
anesthesia  he  is  placed  in  an  almost  sitting  posture  in  a  sling.  Feed- 
ing with  whey  per  orem,  given  with  medicine  dropper  is  tried  early, 
and  brandy  as  needed.  A  sharp  reaction  comes  on  after  the  opera- 
tion— 103,  105  or  106-I-  F.  This  soon  subsides  in  favorable 
cases. 

MALFORMATIONS  OF  THE  SMALL  INTESTINES  AND  COLON 

Neither  the  small  intestine  nor  the  large  is  malformed  so 
frequently  as  the  rectum  or  its  outlet.  Yet  malformation  may  occur 
in  rare  instances  at  any  point.  The  whole  or  a  part  of  the  small 
intestine  may  be  entirely  absent,  or  be  represented  by  a  fibrous  cord, 
nearly  or  quite  impervious.  Or  the  bowel  may  end  in  a  cul-de-sac, 
its  lumen  being  again  resumed  in  a  cul-de-sac,  or  showing  no 
abnormality.  Occasionally  a  diverticulum  from  the  bowel  will  end 
in  a  cul-de-sac,  or  open  upon  the  surface  of  the  abdomen,  the  canal 
below  being  continuous  with  that  above  the  diverticulum  or  sepa- 
rated from  it,  or  undeveloped,  as  the  case,  may  be.  The  whole 
intestine  may  be  abnormally  shortened,  but  not  lengthened.  A  point 
at  which  one  of  the  more  common  diverticula  is  given  off  is  the 
ileum  a  few  feet  above  the  ileo-cecal  valve.  Here  a  remnant  of  the 
omphalo-mesenteric  duct  may  be  found,  and  is  known  as  Meckel's 
diverticulum.  Its  form  varies.  It  may  be  flask-shaped  or  cylindri- 
cal, and  may  end  in  a  blind  extremity  or  open  at  a  fistula  in  the 
abdominal  wall  above  the  umbilicus.  Congenital  atresia  of  the  small 
intestine  is  most  apt  to  occur  in  the  duodenum  about  the  situa- 
tion of  the  bile  duct  and  the  pancreatic  duct,  or  just  where  the 
duodenum  passes  under  the  transverse  meso-colon  to  become  the 
jejunum.  Entero-cysts  are  not  very  uncommon.  They  are  of 
several  varieties,  according  to  their  origin ;  either  springing  from  sub- 
peritoneal tissue  or  consisting  in  an  irregular  segmentation  in  the  de- 
velopment of  the  intestine.  The  large  intestine,  although  seldom 
malformed,  may  be  so  occasionally,  in  either  cecum,  colon,  or  sig- 
moid flexure.  It  may  be  rudimentary,  or  greatly  diminished  in  its 
lumen,  or  its  place  supplied  by  a  mere  cord.  In  rare  instances  the 
cecum  or  the  colon  is  double.  Anomalous  positions  of  the  large 
intestine  are  common,  the  sigmoid  flexure  extending  to  the  middle 
line  or  over  on  the  right  side,  or  the  cecum  occupying  the  middle 
line  or  extending  on  to  the  left  side,  or  being  situated  where 
the  hepatic  flexure  should  be ;  or  cecum  and  appendix  being  found 

1  Richter   (suggested  by  Walls)  :  Surg.  Gynec.  &  Obstet.,  June,  1912. 


570 


SURGICAL   DISEASES    OF   CHILDREN 


in  the  sac  of  an  inguinal  or  scrotal  hernia.  The  causes  of  many  of 
these  malformations  of  the  intestines  are  quite  inexplicable.  Some 
can  be  accounted  for  as  failures  in  certain  steps  of  the  embryo- 
logical  development  which 
are  well  understood,  while 
fetal  peritonitis  and  conse-. 
quent  adhesions  explain  a 
limited  number.  (47) 

Symptoms  and  Diag- 
nosis.— The  symptoms  of 
congenital  malformation  of 
'the  intestine,  large  or 
small,  vary  with  the  na- 
ture and  degree  of  the 
anomaly.  The  diverticula 
often  give  rise  to  no  symp- 
toms at  all,  and  some  with 
an  external  fistula  only  by 
leaking  of  intestinal  con- 
tents. Judging  by  the  loca- 
tion of  a  fecal  fistula  and 
the  character  of  its  dis- 
charge, and  by  probing 
through  it,  some  idea  of 
its  point  of  connection 
with  the  intestine  may 
often  be  formed.  With 
atresia  of  intestine  there 
are  symptoms  of  obstruc- 
tion more  or  less  severe, 
according  to  the  degree  of 
the  occlusion.  Vomiting 
is  a  constant  symptom,  the 
vomited  matters  varying 
according  to  the  seat  of 
obstruction.  If  the  atresia 
is  high  up  in  the  intes- 
tinal tract,  only  whitish 
mucus  will  be  ejected ;  but  if  the  obstruction  is  in  the  ileum, 
or  even  in  the  jejunum,  the  vomitus  will  contain  meconium. 
If  the  occlusion  is  complete,  no  defecation  takes  place.  With 
obstruction  high  in  the  bowel,  distension  of  the  abdomen  with 
meconium  and  feces  or  gases  does  not  take  place  as  it  does 
with  an  obstruction  low  in  the  intestinal  tract.  In  all  cases  it 
is  important  to  explore  the  rectum  to  ascertain  whether  any  mal- 


FiG.  190.  Tuberculosis  and  bron- 
chitis FOLLOWING  MEASLES.  AsciteS 
supervened,  leading  to  diagnosis  of 
tubercular  peritonitis.  Lower  rnar- 
gin  of  liver  shown  by  dark  line. 
Autopsy  showed  death  due  to  an 
old  adhesive  pericarditis.  Boy  aged 
3  years. 


ESOPHAGUS,    STOMACH    AND    INTESTINES  571 

formation  can  be  detected  in  that  situation,  either  by  the  finger  or 
by  a  catheter  or  small  rectal  tube  passed  farther  than  the  finger 
can  reach.  Injections  of  water  may  empty  the  bowel  below  an 
obstruction  and  help  to  demonstrate  its  situation.  Palpation  and 
percussion  may  reveal  the  presence  of  a  tumor,  which  it  may  be 
inferred  is  an  accumulation  above  the  seat  of  the  obstruction.  Inter- 
ference with  the  circulation,  more  marked  upon  one  side  than  upon 
the  other,  may  betray  the  location  of  a  distended  ampulla.  The 
vomiting  of  wdiitish  mucus  alone  might  favor  the  probability  of  a 
high  situation  for  the  obstruction,  but  it  does  not  prove  it  to  a  cer- 
tainty. The  vomiting  of  meconium  indicates  that  the  obstruction 
is  below  the  duodenum,  but  it  gives  no  clue  as  to  whether  it  is  in 
the  small  or  large  intestine.  The  absence  of  vomiting  does  not  dis- 
prove an  intestinal  obstruction.  Nor  is  the  amount  of  urine  of  much 
value  diagnostically.  In  the  great  majority  of  cases  it  is  impossible 
to  determine  with  any  degree  of  accuracy  the  location  of  the  mal- 
formation by  the  symptoms  or  physical  signs. 

Prognosis. — Complete  occlusions  are  fatal  unless  relieved  by 
surgical  means.  With  partial  occlusion  a  patient  may  survive. 
Occlusion  low  in  the  intestine,  which  finds  an  outlet  through  a 
fistula,  is  not  incompatible  with  life.  Quite  a  number  of  malforma- 
tions could  be  remedied  by  operation  if  the  condition  could  be 
determined  and  the  operation  performed  early. 

Treatment. — If  a  fecal  fistula  exist  which  prevents  the  promptly 
fatal  eft'ects  of  complete  obstruction,  or  if,  without  fistula,  the  occlu- 
sion is  evidently  not  complete,  but  allows  the  passage  of  liquid  or 
soft  feces,  it  may  be  advisable  to  wait  until  the  infant  is  older  and 
stronger  before  attempting  operation  for  its  relief.  But  if  there 
is  evidence  of  complete  atresia  or  obstruction  of  such  severe  degree 
as  to  threaten  life  there  is  no  choice  but  to  make  an  exploratory 
incision.  This  may  be  located  in  accordance  with  the  situation  of 
a  fecal  fistula  or  of  a  definite  tumor.  In  the  absence  of  any  guide 
of  this  kind,  the  incision  will  be  made  in  the  median  line.  The 
condition  found  must  be  dealt  with  according  to  its  nature  and  loca- 
tion. If  a  bowel  be  occluded  by  a  septum  the  bowel  must  be  opened 
and  the  septum  divided.  If  the  interruption  in  the  lumen  of  the 
gut  be  longer,  it  may  be  possible  to  bring  the  ends  of  the  normal  gut 
together  and  establish  the  continuity  of  the  canal  by  end-to-end  or 
lateral  anastomosis.  With  hopeless  atresia  in  the  duodenum,  or 
high  in  the  jejunum,  it  may  be  possible  to  perform  a  gastro-jeju- 
nostomy,  uniting  the  stomach  to  the  jejunum  below  the  obstruction. 
If  the  malformation  is  low  in  the  intestinal  tract  an  artificial  anus, 
or  what  is  more  quickly  executed,  a  fecal  fistula,  allowing  the  escape 
of  intestinal  contents  from  the  lowest  portion  of  the  pervious  gut 
to  the  outside  of  the  abdominal  wall,  is  the  .rational  procedure, 


572  SURGICAL  DISEASES    OF   CHILDREN 

These  operations,  although  severe,  are  not  necessarily  fatal,  and 
offer  the  only  hope  of  escape  from  otherwise  inevitable  death. 

INTUSSUSCEPTION 

Intussusception  is  an  invagination  of  one  portion  of  bowel  into 
another  portion — sometimes  described  as  "  telescoping "  of  the 
bowel,  or  prolapse  of  one  portion  of  intestine  into  another.  It  is 
not  exclusively  confined  to  infancy  and  childhood,  yet  more  rarely 
occurs  at  any  other  time  of  life.  It  is  far  more  frequent  in  infancy 
than  in  childhood,  and  is  most  frequent  at  about  the  fourth  to  the 
eighth  month.  It  is  the  most  frequent  of  all  the  causes  of  intestinal 
obstruction  at  this  time  of  life. 

Intussusceptions  of  the  dying  are  in  a  class  by  themselves  and 
have  no  clinical  symptoms.  They  are  found  very  frequently  at 
autopsies  in  the  small  intestines,  especially  of  infants.  They  are 
descending  or  ascending,  easily  reducible,  having  no  swelling  nor 
adhesions,  and  usually  multiple.  They  are  supposed  to  be  caused 
by  irregular  peristalsis  which  takes  place  at  the  moment  of  dissolu- 
tion. I  see  no  reason  for  classifying  them  with  pathological  intus- 
susceptions, and  shall  give  them  no  further  consideration. 

Varieties. — The  invagination  is  nearly  always  descending,  but 
the  ascending  or  retrograde  variety  is  occasionally  seen ;  also  double 
and  triple  invagination  at  the  same  point.  (See  Figs.  191,  192  and 
193.)  Intussusception  may  occur  in  any  part  of  the  intestinal  tract. 
Leichtenstern's  classification  is  as  follows :  The  ileum  into  the 
ileum,  or  ileo-ileac;  the  colon  into  the  colon  or  colon  intussuscep- 
tion ;  the  ileum  through  the  ileo-cecal  valve,  ileo  colic ;  and  the  ileum 
into  the  colon  without  turning  the  valve;  that  is,  the  valve  forms 
the  head  of  the  entering  portion,  ileo-cecal  intussusception.  As  to 
course  and  duration,  the  clinical  classification  of  Rafinesque,  as 
given  by  Treves,  is  satisfactory:  i.  The  ultra  acute,  when  the 
patient  dies  within  the  first  twenty-four  hours.  2.  The  acute,  when 
the  duration  of  the  disease  is  between  two  and  seven  days.  3.  The 
subacute,  when  it  extends  between  seven  and  thirty  days.  4.  The 
chronic,  when  it  lasts  more  than  thirty  days. 

Etiology  and  Pathology. — In  addition  to  age,  which  has  been 
mentioned,  sex,  for  some  unknown  reason,  has  an  influence.  Males 
are  nearly  twice  as  liable  as  females  to  intussusception.  Other  etio- 
logical factors  usually  mentioned  are  anatomical  peculiarities,  such 
as  the  thinness  of  the  intestinal  walls,  the  mobility  of  the  ascending 
colon ;  and,  in  ■  the  ileo-cecal  variety,  the  immobility  of  the  cecum 
and  its  larger  size,  as  compared  with  the  mobility  and  activity  of 
the  lower  end  of  the  ileum,  which  is  of  small  caliber.  Then  there 
is  the  frequency  of  other  intestinal  disorders  at  this  period,  such 
as  indigestion,  colic,  diarrhea,  constipation.     But  Treves,  who  has 


ESOPHAGUS,    STOMACH    AND    INTESTINES 


573 


studied  the  subject  of  intussusception  closely  and  written  upon  it 
extensively,  thinks  that  some  attacks  of  colic  may  be  the  effect  in- 
stead of  the  cause  of  temporary  invaginations  of  the  bowel.  In- 
digestion often  appears  as  a  cause  of  these  cases.  Constipation  is 
given  as  a  cause,  acting  by  inducing  peristalsis,  and  also  by  the  ad- 


/^^ 


:  'M 


\j 


a-r- 


Fig.  191.  Vertical  section  of 
AN  intussusception,  a.  The 
sheath  or  intussuscipiens. 
b.  the  entering  or  inner 
layer,  c.  the  returning  or 
middle  layer,  b.  and  c.  to- 
gether constitute  the  intus- 
susceptum.     After  Treves. 


\S\ 


Fig.  192.  Double 
invagination  of 
intestine.  After 
Treves.  Instances 
of  double  invagin- 
ation are  not  very 
uncommon.  There 
are  five  layers  of 
intestine. 


Fig.  193.  Triple  in- 
vagination OF  in- 
testine. After 
Treves.  Cases  of 
this  variety  are 
quite  unusual. 
Seven  layers  of 
intestine  are  pre- 
sented. 


hesion  of  a  scybalous  mass  to  the  intestinal  wall,  which  is  thereby 
drawn  upon.  Tumor  or  polypus  of  the  intestinal  wall  is  un- 
doubtedly a  cause.  (See  Fig.  194.)  Tumors  are  not  so  very  in- 
frequent, and  range  in  size  from  that  of  a  cherry  to  that  of  an 
egg.  Vegetations  at  the  ileo-cecal  valve  or  an  inverted  Meckel's 
diverticulum  may  act  in  the  same  way.  Leichtenstern  and  other 
writers,  as  quoted  by  Treves,  have  remarked  upon  the  effect  of  the 
ileo-cecal  valve  in  producing  intussusception.  They  compare  the 
valve  to  the  anus,  and  intussusception  through  it  to  prolapse  of  the 
rectum  produced  by  tenesmus.  A  mass  of  undigested  food  has  often 
brought  on  an  intussusception.  This  trouble  has,  in  a  number  of 
instances,  followed  injury  to  the  abdomen  externally.  Sudden  cold 
or  chill,  paralysis,  and  rarely  stricture  are  among  the  causes.     In 


574 


SURGICAL   DISEASES    OF   CHILDREN 


Fig.  194.  Specimen  of  ileo-colic  intussusception  removed  post-mortem 
from  a  child  of  3  years.  Diagnosis  easily  made  during  life  but  oper- 
ation refused.  The  glass  tube  is  passed  through  the  intussusception. 
A  portion  of  the  cecum  forming  the  ensheathing  layer  is  cut  away 
below,  to  show  the  entering  portion  at  the  lower  end  of  which  is  a 
tumor,   which  probably  caused  the  invagination  to  occur. 


ESOPHAGUS,    STOMACH    AND    INTESTINES  575 

my  own  cases  I  was  struck  with  the  frequency  with  which  this 
accident  followed  promptly  after  the  infant  had  been  "  dandled  " 
or  "  tossed,"  or  had  a  slight  fall,  or  was  simply  frightened  by 
nearly  falling,  and  found,  on  consulting  the  literature,  that  Rilliet 
and  Barthez  had  mentioned  three  or  four  such  examples. 

Intussusception  is  produced  by  irregular  action  of  the  muscu- 
lar layers  of  the  intestine.  Anything  that  is  capable  of  exciting  the 
irregular  action  will  act  as  an  exciting  cause.  The  sensation  of 
falling,  acting  through  the  nervous  system,  seems  to  have  that 
power.  The  vivisection  experiments  of  Nothnagel,  as  quoted  by 
Treves,  furnish  important  data  upon  the  subject  of  the  formation 
of  intussusceptions.  The  opinion  is  generally  accepted  that  patho- 
logical intussusceptions  are  produced  in  the  same  manner  as  the 
experimental.  For  example,  the  intestines  of  a  rabbit  are  exposed, 
and  a  segment  of  bowel  stimulated  by  faradism  applied  through 
electrodes,  so  close  together  that  a  ring-like  contraction  is  pro- 
duced. As  the  current  is  increased  the  contraction  extends  a  con- 
siderable distance  upward  (toward  the  stomach),  but  only  to  a  slight 
extent  downward.  The  gut  at  the  point  of  irritation  contracts  to 
a  hard,  white  cord,  and  this  contraction,  proceeding  upward,  either 
widens  gradually  to  normal  intestine  or  ends  abruptly.  In  the  lat- 
ter case  the  wide  tube  of  the  normal  gut  above  slides  a  short  dis- 
tance over  the  contracted  portion  below,  thus  forming  an  ascending 
or  retrograde  intussusception.  Such  invaginations  never  proceed 
far  nor  remain  long.  But  at  the  lower  end  of  the  contracted  por- 
tion a  very  different  occurrence  takes  place.  The  point  at  which 
the  electrode  was  applied  remains  a  fixed  point.  The  normal  gut 
just  below  turns  itself  upward  over  this  contracted  portion  and 
forms  an  intussusception  of  the  descending  variety.  It  was  proven, 
also,  by  paralyzing  a  portion  of  bowel  by  crushing,  that  the  entering 
portion  of  the  intussusception  takes  no  active  part  in  its  formation ; 
and  that  either  spasmodic  contraction  of  a  portion  of  intestine  or 
paralysis  of  a  portion  may  lead  to  the  production  of  an  intussus- 
ception. The  active  part  in  the  process  is  taken  by  the  receiving 
portion  of  the  bowel  (sometimes  called  sheath  or  intussuscipiens), 
which  draws  itself  over  the  entering  portion.  The  entering  portion, 
together  with  the  middle  layer  (that  is,  the  layer  which  turns  back 
from  the  apex  of  the  entering  portion  to  join  the  margin  of  the 
sheath),  is  called  the  intussusceptum.  It  will  be  observed  that  the 
serous  coats  of  the  entering  and  returning  layers  are  in  contact, 
while  two  mucous  coats,  that  of  the  returning  layer  and  that  of  the 
sheath  lie  face  to  face.  If  it  were  not  for  the  mesentery  the  enter- 
ing portion  would  be  straight  and  occupy  the  middle  of  the  sheath. 
But  as  it  enters  it  draws  the  mesentery  in  with  it,  the  latter  lying 
between  the  inner  layer  and  the  sheath,  and  the  dragging  of  the 


576  SURGICAL   DISEASES    OF   CHILDREN 

mesentery  curves  the  entering  portion  into  the  arc  of  a  circle,  with 
its  concavity  toward  the  mesenteric  attachment,  consequently  toward 
the  spine.  To  speak  more  correctly,  in  accordance  with  the  ac- 
cepted theory  of  the  muscular  action,  the  sheath  or  receiving  portion 
engulfs  or  "  swallows  "  the  jntussusceptum,  mesentery  and  all,  the 
latter  being  stretched  to  its  utmost  and  also  constricted  in  the  sheath. 
As  the  invagination  proceeds,  more  and  more  of  the  mesentery  is 
gathered  into  the  neck  of  the  sheath,  making  it  thicker  at  this  part. 
The  apex  of  the  entering  portion  is  drawn  toward  the  side  of  the 
sheath,  and  thereby  partly  obstructed.  This  drawing  upon  one  side 
of  the  intussusceptum  causes  the  orifice  at  its  apex  to  be  slit-like. 
The  degree  of  the  curving  of  the  intussusceptum  varies  considerably, 
according  to  the  part  of  the  intestine  in  which  it  takes  place,  as  a 
rule  being  more  marked  in  ileo-cecal  invaginations,  less  constantly 
present  in  those  of  the  middle  of  the  ileum  and  of  the  colon,  often 
absent  in  the  rectal  variety. 

Invagination  of  the  bowel  does  not  invariably  completely  ob- 
struct its  lumen,  nor  cause  serious  strangulation  of  the  intussus- 
ceptum. Yet  obstruction  and  strangulation,  to  a  degree,  are  always 
present,  and  cause  most  of  the  symptoms.  The  compression  of  the 
mesentery  at  the  neck  of  the  sheath  and  traction  upon  it  interfere 
with  its  circulation,  that  of  the  veins  being  first  affected.  The 
venous  return  being  impeded,  the  intussusceptum  becomes  engorged 
and  edematous.  Hemorrhage  often  occurs.  If  the  strangulation  is 
sufficiently  severe,  and  especially  if  the  arterial  supply  is  prevented, 
gangrene  results.  If  the  strangulation  is  acute,  gangrene  occurs 
near  the  point  of  greatest  pressure  at  the  upper  end  of  the  intus- 
susceptum, which  is  cast  off  in  a  mass.  With  chronic  or  slow  stran- 
gulation, gangrene  begins  at  the  lower  end  of  the  intussusceptum, 
which  sloughs  away  in  pieces,  or  occasionally  ends  acutely  by 
sloughing  away  in  one  continuous  tube  or  en  masse.  The  gan- 
grenous portion  coming  away  may  be  only  a  few  inches  of  bowel 
or  several  feet.  It  may  have  the  serous  side  out  or  if  the  inner 
layer  becomes  loosened  first  it  may  be  passed  with  the  serous  side 
in.  In  the  acute  case,  when  sloughing  of  the  entire  invaginated  por- 
tion occurs,  it  is  generally  in  the  second  half  of  the  second  week. 
The  fragmentary  sloughing  of  the  subacute  or  chronic  case  may 
extend  over  several  weeks.  The  sheath,  or  receiving  portion,  does 
not  show  much  effect  comparatively.  It  usually  is  thrown  into 
folds,  and  somewhat  congested.  It  may  be  thickened.  In  excep- 
tional cases  it  may  show  gangrene.  A  very  important  result  of  the 
invagination  is  the  peritonitis  that  is  set  up,  producing  adhesion 
between  the  serous  coats  of  the  entering  and  the  returning  layers, 
sometimes  involving  the  external  coat  near  the  neck  of  the  sheath. 
Adhesions  may  be  limited  to  the  neck,  where  the  entering  portion 


ESOPHAGUS,    STOMACH    AND    INTESTINES  577 

is  most  tightly  constricted ;  or  limited  to  the  apex ;  or  the  whole  of 
the  serous  surfaces  of  the  entering-  and  returning  layers  may  be 
tightly  glued  together.  The  firmness  of  the  adhesions  varies  greatly 
in  different  cases,  often  being  very  soft  and  easily  separated  and 
offering  no  obstacle  to  reduction.  The  time  at  which  adhesions 
occur  is  a  matter  of  the  greatest  interest.  It  is  rare  that  they  occur 
before  the  fourth  day,  and  not  infrequently  it  is  the  sixth  or  seventh 
day;  while  chronic  intussusception  may  be  present  for  weeks,  or 
for  months,  without  the  formation  of  adhesions. 

Symptovu. — In  the  typical  acute  form  the  symptoms  are  sud- 
den pain,  and  vomiting  of  the  stomach  contents.  The  pain  is 
paroxysmal,  recurring  every  few  minutes,  and  is  very  severe.  There 
are  symptoms  of  shock — feeble  pulse,  pallor,  the  abdominal  and  other 
muscles  relaxed,  mental  apathy.  The  temperature  may  remain 
normal  but  is  often  subnormal.  Tenesmus  is  a  common  symptom, 
usually  said  to  occur  in  rectal  intussusception ;  but  in  my  experience 
something  very  like  it  occurs  during  the  paroxysm  of  pain  in  the 
ileo-cecal,  ileo-colic,  and  colic  varieties.  Soon  defecation  occurs. 
After  the  lower  bowel  has  been  emptied  of  fecal  matter,  blood  is 
passed — blood  and  serum.  A  tumor  may  be  felt,  often  in  some  part 
of  the  colon,  or  in  the  rectum.  If  the  case  does  not  die  of  shock 
within  the  first  forty-eight  hours,  the  abdomen,  hitherto  soft  and  re- 
laxed, becomes  tympanitic.  The  vomiting  has  continued  and  brings 
up  bile-stained  mucus,  or  is  stercoraceous  in  older  children,  or 
is  a  mere  empty  retching.  If  the  condition  is  not  relieved,  the 
prostration  becomes  extreme,  the  temperature  rapidly  rises  to 
102,  103,  105,  or  106  degrees  F.,  and  the  end  comes  with  coma  or 
collapse. 

The  subacute  cases  present  the  same  symptoms,  but  the  onset 
is  not  so  sudden  nor  the  symptoms  so  severe. 

In  the  chronic  cases  the  symptoms  are  very  indefinite.  There  is 
usually  some  diarrhea,  sometimes  with  straining,  and  irregular  pains 
and  discomfort.  The  child  is  worrisome  and  loses  flesh.  But  there 
is  no  acute  pain,  vomiting,  bloody  stools  nor  collapse.  Tumor  may 
generally  be  found  by  palpation  or  rectal  exploration. 

Pain. — Pain  is  one  of  the  most  constant  symptoms,  being  almost 
invariably  present  in  the  acute  cases.  It  is  extremely  severe,  caus- 
ing the  child  to  shriek  with  agony.  After  a  momentary  paroxysm 
it  ceases,  to  return  again  after  a  few  minutes,  as  in  ordinary  colic, 
but  much  more  severe.  The  child's  face  wears  a  look  of  fear  and 
anxiety  as  if  in  dread  of  the  pain.  Pain  may  become  less  severe  after 
twenty-four  or  forty-eight  hours,  in  some  cases  being  less  noticed 
after  the  first  few  hours,  perhaps  from  the  apathetic  condition  pro- 
duced in  the  child.  Children  are  generally  unable  to  localize  the 
pain.    In  some  cases  pain  is  not  so  prominent,  its  place  being  taken 


578  SURGICAL   DISEASES    OF   CHILDREN 

by  paroxysmal  tenesmus.  This  is  more  apt  to  be  the  case  in  the  sub- 
acute variety. 

Vomiting  is  almost  invariably  present  in  acute  cases,  though  it 
does  not  alv/ays  begin  early.  When  once  begun  it  continues  more 
or  less  throughout  the  attack.  It  is  not  as  prominent  nor  as  dis- 
tressing a  symptom  as  in  other  forms  of  intestinal  obstruction.  It 
varies  somewhat  according  to  the  completeness  of  the  obstruction. 
and  is  made  worse  when  food  is  given  by  the  stomach.  It  oc- 
curs with  the  obstruction  at  any  part  of  the  intestinal  tract.  It 
is  not  much  affected  by  medication,  but  is  not  often  violent.  I 
have  never  considered  it  markedly  projectile.  In  older  children  if 
vomiting  persists  several  days  it  becomes  stercoraceous.  In  a  few 
cases  it  is  bloody. 

Tumor. — This  is  a  very  important  symptom,  because  it  is  char- 
acteristic, and,  fortunately,  may  usually  be  found  readily  if  search 
be  made  within  the  first  day  or  two,  while  the  abdomen  is  relaxed 
and  free  from  tympanites  or  tenderness.  Tumor  may  be  present 
within  a  few  hours  after  the  onsets  In  Holt's  collection  of  i88 
cases  under  ten  years  of  age,  one-half  presented  the  tumor  in  the 
rectum  or  protuding  from  the  anus.  And  this  descent  may  take  place 
in  a  very  short  time,  even  when  beginning  at  the  ileo-cecal  valve. 
In  one  of  his  own  cases  it  was  felt  in  the  rectum  in  less  than  twelve 
hours  after  the  onset.  This  seems  a  surprisingly  large  proportion 
of  cases  to  be  first  found  as  low  as  the  rectum  if  they  were  all 
acute  cases.  It  goes  to  show  how  long  and  loose  the  mesentery  may 
be.  Digital  examination  by  the  rectum  miay  find  the  tumor  there, 
or  even  protruding  an  inch,  or  two,  or  three,  or  more.  It  may  pre- 
sent the  ileo-cecal  valve  at  its  apex.  Often  the  sphincter  will  be 
found  relaxed  if  the  tumor  is  low  in  the  colon  or  rectum.  One  of 
my  cases  was  a  babe  of  ten  m.onths,  which  had  been  ill  betweon 
five  and  six  weeks.  It  began  with  pain,  vomiting  and  purging,  with 
bloody  stools,  but  no  physician  had  been  called  during  the  first  two 
weeks.  Then  the  doctor  made  eight  visits  and  checked  the  symp- 
toms, which,  however,  still  recurred.  During  the  last  ten  days  or 
two  weeks  the  mother  had  noticed  a  "  lump  "  in  the  lower  part  of 
the  baby's  belly.  Attacks  of  tenesmus  were  frequent,  and  each  time 
the  "  bowel  came  out "  a  distance  of  two  inches.  The  ready-made 
diagnosis  was  "  dysentery,"  with  prolapse  of  the  rectum.  Examina- 
tion showed  the  projecting  tumor  an  intussusception,  of  the  usual 
purple  color  and  opening  at  the  apex  like  an  os  uteri.  Apparently 
the  entire  colon  from  the  cecum  was  invaginated.  It  was  afterward 
reduced  by  water  pressure  and  the  babe  recovered.  If  the  tumor  is 
not  found  in  the  rectum,  search  should  be  made  by  palpation  over  the 
course  of  the  sigmoid,  descending,  transverse  and  ascending  colon, 
and  especially  in  the  ileo-cecal  region,  where  so  many  intussuc- 
ceptions  begin.    The  tumor  may  be  small,  of  the  size  of  a  hickory- 


ESOPHAGUS,    STOMACH    AND    INTESTINES  579 

nut,  or  several  inches  in  length  and  "  sausage  shaped,"  that  is. 
crescentic,  with  the  concavity  toward  the  mesenteric  attachment  at 
the  spine.  If  taking  its  origin  low  in  the  colon  or  in  the  rectum, 
this  curved  shape  is  not  noticeable.  It  is  usually  movable  and  may 
be  felt  to  swell  and  become  tense  during  manipulation  or  during 
a  paroxysm  of  pain  and  tenesmus.  It  may  be  difficult  to  discover 
if  under  the  margin  of  the  liver ;  or  if,  after  the  first  day  or  two  of 
relaxation  of  the  muscles,  they  become  tense  with  the  advent  of 
peritonitis ;  or  tenderness  supervenes,  leading  to  resistance  from 
the  patient ;  or  the  abdomen  is  tympanitic.  An  anesthetic  may  be 
necessary  to  discover  the  tumor. 

SJiock  or  Prostration. — This  is  a  marked  symptom  in  the  acute 
cases.  It  would  require  a  severe  external  injury  or  a  serious  opera- 
tion to  produce  an  equal  degree  of  depression.  Colic  never  pro- 
duces such  prostration.  Strangulated  hernia,  some  forms  of  poison- 
ing, or  cholera  infantum  might  do  so.  The  feeble  pulse,  cold,  some- 
times perspiring  skin,  subnormal  temperature,  relaxed  musculature 
and  the  anxious  countenance,  and  later  apathy,  are  sufficient  evi- 
dence that  a  grave  accident  has  occurred. 

The  Stools. — Bloody  stools  are  a  very  constant  symptom.  There 
are  sometimes  a  few  loose  fecal  stools  first,  but  very  soon,  in  the 
majority  of  cases,  blood  appears.  Often  there  is  quite  a  quantity; 
that  is,  enough  to  stain  a  diaper  freely  with  watery  blood.  It  is 
said  that  mucus  is  nearly  always  present.  But  in  my  cases  this 
has  not  usually  been  present  early  in  the  case.  Appreciable  quan- 
tities of  mucus  come  later  in  the  acute  cases,  or  in  the  subacute  and 
chronic  cases.  In  these  latter  it  is  a  feature  and  lends  some  resem- 
blance to  dysentery.  I  have  but  a  few  times  seen  in  colitis  enough 
clear  blood  to  resemble  the  stools  of  intussusception ;  and  never 
in  acute  intussusception  anything  like  the  quantity  of  mucus  ordi- 
nary in  colitis.  In  intussusception  the  stools  soon  lose  all  fecal  odor, 
and  finally  they  may  cease  altogether,  scarcely  anything,  not  even 
gas,  passing  during  the  straining.  In  other  cases  there  is  a  little 
blood  or  bloody  mucus. 

Temperature. — The  most  important  thing  about  the  temperature 
is  the  absence  of  fever  early  in  the  case.  This  or  subnormal  tem- 
perature are  usual.  If,  later,  temperature  rises  rapidly,  it  presages 
a  promptly  fatal  termination. 

Anuria. — The  urine  may  be  diminished,  but  the  symptom  is  not 
marked  and  is  of  no  value  in  indicating  a  high  or  lower  seat  of 
obstruction. 

Thirst. — Thirst  is  not  a  symptom  unless  vomiting  and  bleeding 
are  profuse — in  marked  contrast  with  many  gastric  disorders  and 
diarrheas  and  some  forms  of  strangulation  bearing  a  resemblance  to 
intussusception. 

Loss  of  weight  takes  place  in  the  subacute  and  chronic  cases. 


58o  SURGICAL   DISEASES    OF    CHILDREN 

In  the  acute  cases,  although  some  loss  takes  place,  it  is  not  as  much 
as  indicated  by  appearances,  which  are  rather  due  to  the  flaccid 
state  of  the  muscles. 

Course  and  Prognosis. — Treves  gives  the  general  mortality  of 
intussusception  as  70  per  cent.  Among  acute  cases  alone  the  mor- 
tality is  much  higher,  and  the  ultra-acute  cases  are  all  fatal.  Most 
of  the  recoveries  are  among  the  subacute  cases.  The  distinctly 
chronic  cases  have  a  high  mortality.  And  in  children  under  a  year 
the  mortality  is  high,  as  compared  with  cases  at  all  ages.  In  over 
80  per  cent,  of  the  cases  death  occurred  before  the  seventh  day. 
Holt  gives  the  following  figures :  Of  198  cases  under  ten  years, 
155  were  classed  as  acute,  lasting  less  than  seven  days;  33  as  sub- 
acute, lasting  from  one  to  four  weeks ;  10  were  chronic,  lasting  over 
four  weeks.  Nearly  all  the  cases  occurring  in  infancy  are  acute. 
The  duration  of  the  disease  in  92  fatal  cases  was  as  follows :  Less 
than  twenty-four  hours,  2  cases ;  two  to  four  days,  44  cases ;  five  to 
seven  days,  22  cases ;  one  to  two  weeks,  18  cases ;  two  to  three 
weeks,  6  cases.  Thus  one-half  the  cases  died  on  the  third,  fourth, 
or  fifth  day.  Of  57  cases  terminating  in  recovery,  66  per  cent,  were 
reduced  on  the  first  or  second  day. 

In  the  acute  cases  the  most  frequent  cause  of  death  is  shock. 
In  the  chronic  cases  it  is  usually  exhaustion.  Peritonitis,  hemor- 
rhage from  separation  of  gangrenous  gut,  pyemia,  and  perforation 
are  among  the  causes  of  death. 

Spontaneous  cure  of  intussusception  may  result,  although  these 
instances  are  so  rare  and  uncertain  they  are  never  to  be  counted 
upon  in  the  prognosis  or  treatment.  Spontaneous  cure  may  take 
place  in  one  of  two  ways — reduction  of  the  intussusception  or  elim- 
ination of  the  intussusceptum  by  gangrene,  while  adhesions  at  the 
neck  of  the  sheath  maintain  the  continuity  of  the  intestinal  tube. 
Treves  and  other  observers  have  little  doubt  that  spontaneous  reduc- 
tion occasionally  takes  place,  perhaps  oftener  than  has  been  sup- 
posed. In  one  case  of  my  own,  in  a  boy  of  three  years,  I  carefully 
eliminated  all  other  causes  of  the  condition,  which  must  have  been 
an  intestinal  obstruction,  and  in  all  probability  an  intussusception, 
which  righted  itself  under  the  prompt  use  of  opium.  Such  cases 
are,  of  course,  impossible  of  proof,  yet  to  one  familiar  with  children's 
attacks  of  vomiting,  indigestion,  colic,  gastro-enteritis,  ileo-colitis 
and  the  like,  the  clinical  picture  presented  by  intussusception,  with 
its  sudden  onset  in  a  well  child,  its  acute  pain,  vomiting,  tenesmus, 
collapse,  even  without  tumor,  is  hardly  to  be  mistaken.  And  to  see 
this  condition  as  suddenly  righted  admits  of  but  one  reasonable  con- 
clusion. There  is  every  reason  to  suppose,  from  experiment  and 
from  recorded  clinical  cases,  that  spontaneous  reduction  takes  place. 
As  to  cure  by  sloughing  of  the  intussusceptum,  there  is  abundant 


ESOPHAGUS,    STOMACH    AND    INTESTINES  581 

evidence  in  the  records  and  in  the  pathological  museums.  Accord- 
ing- to  Leichtenstern,  recovery  by  this  method  in  the  first  year  of 
life  takes  place  in  only  2  per  cent,  of  the  cases,  between  the  second 
and  fifth  years  in  6  per  cent.,  and  between  the  sixth  and  tenth  years 
in  38  per  cent.  Of  those  who  do  recover  from  the  immediate  attack 
by  elimination  of  the  intussusception,  over  40  per  cent,  die  ulti- 
mately from  the  effects  of  the  bowel  lesion.  (Leichtenstern, 
Treves.) 

Diagnosis. — The  diagnosis  is  made  upon  the  sudden  onset  of 
paroxysmal  pain,  the  vomiting,  shock,  bloody  stools,  tumor,  and 
subnormal  temperature.  If  the  examination  is  made  while  the 
abdominal  muscles  are  yet  relaxed — that  is,  in  the  first  day  or  two 
days — no  anesthetic  is  necessary.  But  after  tympanites  occurs,  or 
peritonitis  or  local  tenderness  at  the  site  of  the  tumor  appear,  mus- 
cular rigidity  or  voluntary  resistance  or  fear  of  being  hurt  will 
make  general  anesthesia  necessary  for  satisfactory  examination. 
In  the  chronic  cases  the  presence  and  character  of  the  tumor  when 
discovered,  together  with  the  more  indefinite  symptoms,  usually 
settle  the  diagnosis  at  once.  Yet  mistakes  have  occurred,  even  with 
the  tumor  projecting  from  the  anus  or  plainly  palpable  in  the  rec- 
tum, it  being  mistaken  for  prolapse  or  polypus,  or  even  for  hemor- 
rhoids or  a  cancerous  growth.  The  opening  at  the  apex  should  dis- 
tinguish an  intussusception  from  any  tumor ;  and  that  one  can 
sweep  a  finger  all  round  it,  there  being  no  attachment  at  the  anal 
margin,  dispels  any  superficial  appearance  of  prolapsus. 

Treatment. — A  few  words  are  necessary  concerning  the  opium 
treatment  of  intussusception.  Treatment  by  opium  has  done  incal- 
culable harm ;  there  is  no  other  drug  that  has  been  so  misused  and 
has  caused  so  many  deaths  from  intussusception  as  opium  (and  its 
derivatives)  ;  and  this  notwithstanding  that,  if  used  wisely,  it  is 
a  valuable  medicine  in  this  condition.  If  men  would  use  opium 
as  they  would  an  anesthetic,  understanding  that  it  is  only  useful 
temporarily,  in  order  thereby  to  accomplish  something  else  that  is 
positively  remedial,  its  use  would  be  justifiable.  But  the  relief 
it  affords  from  pain,  sometimes  from  vomiting,  from  the  appear- 
ance of  shock,  from  tenesmus,  and  consequently  from  the  bloody 
stools,  this  relief,  I  say,  is  so  specious  that  it  deceives  the  physi- 
cian himself,  blinds  him  to  the  real  condition,  and  leads  him  to 
postpone  active  measures.  It  is  sure  to  deceive  the  parents  and 
cause  them  to  oppose  any  mechanical  solution  of  the  difficulty.  And 
so  the  time  most  favorable  for  reduction  is  allowed  to  pass  by. 
There  is  no  doubt  whatever  that  in  rare  instances  the  ]:)rompt  use 
of  opium  has  checked  the  irregular  action  of  the  intestinal  muscu- 
lar coats,  which  had  produced  an  intussusception,  and  with  every 
recurring  paroxysm  was  drawing  it  farther  and  tighter,  and  that 


582  SURGICAL   DISEASES    OF   CHILDREN 

the  entering  bowel,  released  from  the  muscular  grip  of  the  receiv- 
ing portion,  has  righted  itself.  But  these  instances  are  rare  and  are 
not  to  be  counted  upon  as  probable  effects  of  opium.  When  they 
do  occur  it  is  promptly  after  the  exhibition  of  the  drug.  They  argue 
nothing  for  its  repeated  or  continued  use.  It  is  true  that  opium 
will  relieve  shock,  but  that  is  no  reason  for  allowing  the  cause  of 
the  shock  to  continue  to  act.  Opium  quiets  the  tenesmus  and  thus 
checks  the  increase  of  the  intussusception. 

Belladonna  is  a  useful  drug,  used  in  connection  with  the  opium. 
It  aids  in  relieving  the  pain  and  in  quieting  irregular  spasmodic 
peristalsis.  One  or  both  of  these  drugs  may  be  used  in  suppository 
when  the  stomach  is  intolerant.  This  temporary  staying  of  the 
progress  of  the  intussusception  should  be  utilized  for  making  the 
necessary  arrangements  for  permanent  relief  by  reduction  either 
without  or  with  laparotomy,  as  may  prove  to  be  necessary. 

Obstacles  to  Reduction. — Just  at  this  point,  before  discussing 
the  means  of  effecting  reduction,  it  may  be  useful,  at  the  risk  ot 
repetition,  to  refer  again  to  the  pathology  of  the  condition,  with  an 
eye  solely  to  its  reducibility.  Early  in  the  case  the  greatest  obstacle 
to  reduction  is  the  swelling  of  the  intussusceptum,  together  with 
the  spasmodic  contraction  of  the  sheath ;  other  causes  that  may 
develop  are  the  curved  shape  of  the  intussusceptum,  together  with 
the  stiffness  produced  by  the  edema ;  gripping  of  the  tumor  by 
the  sphincter-like  ileo-cecal  valve  in  the  ileo-colic  variety ;  twisting 
of  the  tumor;  and  adhesions  between  the  serous  coats  of  the  enter- 
ing and  the  returning  layers.  Adhesions  never  appear  sooner  than 
the  third  day,  seldom  before  the  fourth,  and  often  not  until  the 
sixth  or  seventh.  It  is  not  uncommon  for  them  to  be  absent  for 
weeks  in  the  subacute  cases.  In  chronic  cases  there  are  apt  to  be 
adhesions.  Occasionally  there  are  adhesions  only  near  the  apex 
of  the  intussusception,  so  that  when  all  is  disinvaginated  but  the  last 
inch  perhaps,  the  adhesions  prevent  farther  reduction,  but  this  is 
unusual.     New  adhesions  are  soft  and  yielding,  easily  torn  apart. 

The  Amount  of  Pressure  borne  by  the  intestine  without  rupture 
is  stated  by  Forest,  after  experimental  study  of  the  subject,  to  be 
eight  or  nine  pounds  to  the  square  inch  in  the  infant  and  twelve  to 
fifteen  pounds  in  the  adult.  When  rupture  takes  place  it  is  usually 
in  the  transverse  colon.  Six  pounds  pressure  was  considered  by 
him  a  safe  amount  to  apply  in  a  child  during  the  first  three  days  of 
the  illness,  and  he  advised  the  use  of  eight  or  nine  pounds  if  neces- 
sary. In  a  subacute  or  chronic  case  the  same  amount  would  be  safe 
any  time  within  a  week  to  perhaps  three  weeks. 

Softening  or  Sloughing  of  the  Bozvd. — -Another  question  of 
extreme  importance  bearing  upon  reduction  is.  When  may  slough- 
ing of  the  affected  intestine  begin?     According  to  Forest,  in  the 


ESOPHAGUS,    STOMACH    AND    INTESTINES  583 

ultra-acute  cases,  sloughing  may  begin  in  twenty-four  hours.  In 
the  ordinary  acute  cases,  three  days  is  the  minimum  time,  while  in 
the  subacute  and  chronic  cases  a  week  or  more  will  elapse  before 
any  change  of  that  kind  takes  place. 

Methods  of  Reduction. — The  literature  records  many  curious 
methods  for  reduction  which  are  now  obsolete;  for  example,  the 
introduction  of  quantities  of  quicksilver  into  the  bowel  with  the 
patient  inverted ;  the  use  of  bougies  to  push  up  the  tumor  and  so 
effect  reduction.  Cures  are  recorded  by  all  these  methods.  Also 
by  introducing  into  the  child's  colon  a  sheep's  colon  and  then  inflat- 
ing the  latter  with  air. 

Puncture  of  the  intestine  with  the  fine  tube  of  an  aspirator  is 
a  procedure  not  only  useless  in  a  curative  way,  but  unsurgical  and 
dangerous.  It  was  used  to  prolong  life  by  relieving  gaseous  dis- 
tension while  waiting  for  sloughing  of  the  gut.  I  would  not  have 
mentioned  it  here  but  that  I  saw  it  alluded  to  without  condemnation 
among  the  remedial  measures  in  a  recent  book. 

The  lines  of  procedure  which  are  worthy  of  discussion  are 
abdominal  taxis,  reduction  by  the  pressure  of  air  or  of  gas  intro- 
duced below  the  tumor ;  reduction  by  pressure  of  fluids ;  laparotomy 
with  disinvagination ;  laparotomy  with  exsection  of  the  intussus- 
ceptum  or  other  entero-plastic  operation ;  and  combinations  of  these 
methods. 

Abdominal  taxis  as  nearly  as  possible  after  the  manner  of 
manipulating  a  hernia,  but  through  the  abdominal  walls,  was  advo- 
cated by  Mr.  Jonathan  Hutchinson.  Cures  are  reported  from  this 
method  alone,  but  it  is  better  and  usually  combined  with  inflation 
or  injection.  (48) 

In  1892  and  at  intervals  subsequently  I  made  some  studies  of 
the  subject  of  intussusception,  my  conclusions  being  briefly  stated 
in  an  article  published  later.^  In  this  article  I  drew  attention  to  the 
necessity  of  accurately  measuring  the  pressure  employed  for  reduc- 
tion, and  especially  emphasized  the  fact  that  the  element  of  time 
during  which  the  pressure  is  kept  up  is  of  equal  importance  with 
the  degree  of  the  pressure,  stating  my  opinion  that  a  pressure  of 
three  to  five  pounds  to  the  square  inch  applied  for  twenty-five  or 
thirty  minutes,  or,  if  necessary,  longer,  is  more  efficient  and  safer 
than  a  pressure  of  seven  to  nine  pounds  for  five  or  ten  minutes. 
I  criticised  reporters  of  cases  for  indefiniteness  upon  these  points, 
many  writers  saying  "  we  used  injections  persistently,"  or  "  infla- 
tions," or  "  we  inflated  the  bowels  repeatedly,"  very  seldom  stating 
the  amount  of  pressure  used,  and  in  no  case  recorded  had  I  found 
mention  made  of  the  length  of  time  during  which  the  pressure 
should  be  maintained  at  a  given  degree.     As  stated  in  that  article, 

1  Cleveland  Medical  Gazette,  March,  1898. 


584  SURGICAL   DISEASES    OF   CHILDREN 

and  even  yet  to-day,  our  text-books  are  very  indefinite  on  these 
points,  especially  as  regards  the  element  of  time. 

The  condition  is  somewhat  analogous  to  that  of  incarcerated 
hernia.  No  surgeon  would  think  of  seizing  a  hernial  protrusion 
and  at  once  by  the  exertion  of  force,  even  of  a  measured  amount 
of  force,  thrusting  it  through  its  constricting  ring  into  the  abdomen. 
On  the  contrary,  continuous  and  steady  pressure  is  applied  and 
kept  up  for  a  time  sufficient  in  many  instances  to  lessen  the  swelling 
and  to  tire  out  the  spasmodically  contracted  muscular  bands,  while 
at  the  same  time  manipulation  at  the  neck  of  the  sac  aids  in  the 
taxis.  In  the  same  manner  the  steady  pressure  of  air,  or  gas  or  fluid 
within  the  bowel  below  the  intussusception  not  only  tends  to  push 
it  back  but  lessens  its  congestion  and  edema  and  so  its  caliber  while 
the  ensheathing  layer  is  also  expanded  and  its  spasmodic  constric- 
tion forced  to  yield.  I  urged  the  use  of  normal  saline  solution  at 
a  temperature  of  100  to  105,  or  of  air  followed  by  water.  This 
was  suggested  as  a  means  not  only  of  preventing  the  escape  of  air, 
which  is  very  difficult  to  keep  in  the  colon  under  pressure,  but  of 
measuring  the  pressure  of  the  air  by  the  simple  method  of  following 
it  with  water-pressure  measured  by  the  elevation  of  the  fountain. 
I  do  not  believe  that,  as  one  writer  states,  "  the  amount  of  air  in- 
troduced should  be  left  to  the  judgment  of  the  physician,"  unless 
he  has  some  means,  more  reliable  than  guessing,  of  estimating  the 
tension  produced.  At  the  time  of  that  writing  I  had  not  seen 
Forest's  original  paper,^  and  was  not  aware  that  he  had  alluded 
to  the  advantage  of  continuous  pressure. 

For  inflation  air  may  be  used,  or  carbonic  acid  gas,  or  hydrogen 
gas.  Ziemssen's  method  (or  that  of  Libur  or  Jate)  of  using  car- 
bonic acid  gas  by  injecting  into  the  bowel  first  a  solution  of  bicar- 
bonate of  soda  and  afterward  a  solution  of  tartaric  acid,  is  only 
mentioned  in  order  to  condemn  it.  The  use  of  a  siphon  of  Vichy 
water  as  employed  by  Forest  was  afterward  justly  censured  by  the 
same  writer  because  of  the  uncertainty  as  to  the  amount  of  force 
used.  Hydrogen  gas,  after  the  method  of  Senn  in  wounds  of  intes- 
tines, could  be  used,  but  the  apparatus  is  seldom  at  hand  and  pos- 
sesses no  advantage  over  common  air. 

Whatever  agent  is  employed,  the  degree  of  force  and  the  time 
it  is  kept  in  action  should  be  accurately  measured.  The  advantages 
of  air  are:  The  elasticity  of  its  pressure  within  the  bowel;  and  the 
fact  that  if  reduction  is  effected  pressure  is  relieved  so  promptly 
that  it  can  be  felt  by  the  manipulating  hand  upon  the  abdomen ;  and 
most  convenient  of  all,  if  the  pressure  is  released  the  air  recedes  so 
readily  that  the  tumor  may  be  searched  for  at  once.  Air  passes 
more  readily  than  water,  above  the  ileo-cecal  valve  into  the  small 
intestine. 

Am.   Jour,    of   Obst.,  July,    1886. 


ESOPHAGUS,    STOMACH    AND    INTESTINES  585 

Its  disadvantages  arc :  It  is  less  manageable,  that  is,  harder 
to  confine  within  the  sphincter,  and  hard  to  maintain  at  the  desired 
pressure.  This  difficulty,  however,  has  been  overcome,  as  I  men- 
tioned, by  first  filling  the  bowel  with  air  and  then  following  with 
water  at  a  measured  pressure — which  drives  the  air  before  it  higher 
into  the  bowel 

Of  the  fluids  used  for  injection  there  are  several — plain  water, 
soapy  water,  normal  saline  solution,  oil,  milk,  thin  gruel,  beef  tea ; 
not  to  mention  decoction  of  tobacco  or  of  chamomile  and  other 
fluids  that  have  occasionally  been  used.  Of  these  the  best  and  most 
available  is  water  that  has  been  boiled  and  cooled  to  such  a  tem- 
perature that  it  will  be  delivered  to  the  patient  at  105  degrees  to 
100  degrees  F.,  and  it  should  have  in  solution  common  salt,  a  drachm 
to  the  pint.  The  advantages  of  such  a  solution  are:  It  is  quite 
manageable  at  a  given  pressure.  It  can  be  used  hot  or  quite  warm, 
thus  aiding  in  overcoming  shock;  and  doubtless  some  of  it  will 
absorbed  from  the  intestine,  stimulating  the  patient  and  supplying 
water  for  the  circulation. 

Its  disadvantages  are :  It  is  not  quite  so  readily  apparent  when 
the  intussusception  yields,  as  the  tension  does  not  alter  so  instantane- 
ously ;  and  if  pressure  is  relaxed,  the  bowel  is  not  at  once  emptied, 
so  that  one  cannot  immediately  search  for  the  tumor.  It  has  been 
said  to  cause  diarrhea.  However,  I  have  never  seen  diarrhea  caused 
thus.  In  my  own  practice  I  vise  the  hot  normal  saline,  first  filling 
the  bowel  with  air  from  a  bellows  or  an  ordinary  hand  ball  with 
a  valve,  such  as  is  used  with  an  atomizer,  attached  to  a  catheter. 

It  is  usually  directed  that  the  patient's  hips  should  be  elevated, 
or  that  the  patient  should  be  inverted  from  time  to  time,  in  order 
"  to  get  the  assistance  of  traction  of  the  intestine  above  upon  the 
seat  of  the  invagination,"  or  that  the  "  water  in  the  intestine  may  as- 
sist by  gravity."  As  matters  of  fact  one  may  state  that  the  traction 
of  the  weight  of  the  intestine  or  of  the  water  would  be  quite  incon- 
siderable even  if  in  the  right  direction ;  and  that  the  force  may  be 
desired  transversely  in  the  transverse  colon  or  toward  the  feet  in 
the  ascending  colon.  What  inversion  (as  well  as  manipulation) 
might  do  is,  to  favor  the  passing  of  air  or  of  fluid  upward  through 
the  ileo-cecal  valve,  as  Forest  has  shown,  and  as  my  own  experi- 
ments corroborate.  But,  as  before  stated,  it  is  extremely  rare  to 
have  intussusception  of  the  small  intestine  alone  in  children ;  and 
it  is  impossible  to  affect  such  an  obstruction  above  the  valve  by 
air  or  water  pressure  without  unsafe  tension  on  the  colon. 

The  simple  device  of  Forest  is  quite  as  efficient  as  the  elaborate 
apparatus  of  Mr.  Lund.  The  nozzle  of  an  ordinary  Davidson  syringe 
or  a  vaginal  syringe  should  be  wound  with  a  roller  bandage  about 
an  inch  from  its  tip  so  as  to  make  a  shoulder  an  inch  wide,  which  may 
be  pressed  against  the  buttocks  to  prevent  the  water  from  escaping. 


586  SURGICAL   DISEASES    OF   CHILDREN 

This  with  a  fountain  syringe  and  some  rubber  tubing  constitutes 
the  hydrostatic  machinery.  I  usually  have  twenty  to  twenty-five 
feet  of  rubber  tubing,  as  a  stairway  to  get  the  proper  elevation  may 
not  be  near.  I  have  allowed  two  and  one-half  feet  elevation  to 
represent  one  pound  pressure  to  the  square  inch.^  Beginning  at 
the  height  of  the  patient  upon  the  table  I  mark  the  stairway,  in  an 
ascending  scale,  at  intervals  of  two  and  one-half  feet,  numbering 
the  marks,  so  that  the  person  who  holds  the  fountain  can  be  directed 
verbally.  An  anesthetic  is  administered.  The  patient  lies  upon  his 
back  with  thighs  flexed  and  is  held  firmly,  as  one  is  obliged  to 
press  the  shoulder  of  the  injection  tube  strongly  against  the  buttocks. 
Air  is  then  pumped  in  and  then  the  water  allowed  to  flow.  A  case 
or  two  will  illustrate.  Baby  M.,  aged  four  months,  was  well  grown, 
breast-fed,  and  healthy,  though  the  bowels  were  slightly  loose.  At 
eight  o'clock  one  evening  suddenly  turned  sick,  cried  with  pain, 
vomited,  and  defecated.  Vomited  at  intervals  all  night,  the  vomitus 
becoming  green.  After  a  few  fecal  stools  the  discharges  became 
bloody  serum.  Paroxysms  of  pain  and  tenesmus.  Refused  the 
breast.  Temperature  normal ;  pulse  very  rapid ;  child  apathetic ; 
weak ;  pale ;  muscular  system  entirely  relaxed.  Abdomen  flaccid. 
In  the  cecal  region  a  movable  tumor  thicker  than  my  thumb  could 
not  only  be  felt  but  seen.  Palpation  of  tumor  caused  paroxysms 
of  pain.  Diagnosis  intussusception,  probably  ileo-cecal.  Gave  a 
small  opiate ;  and  procured  apparatus  for  reduction.  Assisted  by 
Drs.  Bailey  and  Barger.  Chloroform.  Inflated  with  air  followed  by 
water  to  maintain  and  measure  the  pressure  (normal  saline  T.  103 
F.).  Fountain  at  five  feet  four  inches,  giving  a  trifle  over  two 
pounds  pressure  per  square  inch.  Kept  this  pressure  fifteen  min- 
utes. Raised  reservoir  to  six  feet  four  inches,  giving  pressure  nearly 
two  and  a  half  pounds  and  kept  this  up  five  minutes  longer,  making 
twenty  minutes  in  all  under  pressure.  There  was  not  felt  any  per- 
ceptible giving  way,  but  the  respiration  and  circulation  being  im- 
peded by  the  pressure  it  was  now  relaxed,  and  the  water  allowed  to 
escape.  It  was 'then  found  that  the  tumor  had  disappeared.  In- 
fant vomited  a  few  times  after  the  reduction,  then  became  quite 
easy  and  recovered. 

Another  illustrative  case  is  Baby  D.,  aged  nine  months.  Seen 
with  Dr.  Nuss.  While  sitting  on  the  floor  he  toppled  over  back- 
ward, which  scared  the  infant  without  apparently  hurting  him. 
Soon  after  he  cried  with  pain,  and  was  much  distressed.  Vomiting 
ensued,  and  a  bowel  movement  with  much  tenesmus.  Could  retain 
no  food  in  the  stomach.  Was  seen  by  me  fifty-six  hours  later.  He 
was  restless,  tossing  and  turning  and  kicking ;  apathetic ;  temperature 

1  Forest,  in  his  paper  of  1886,  reckoned  two  and  one-half  feet;  in 
his  paper    of    1889,  two  feet. 


ESOPHAGUS,    STOMACH    AND    INTESTINES  587 

99§,  pulse  158.  Straining  at  intervals,  passing  small  quantities  of 
blood-stained  mucus.  No  stool  in  past  fifty-six  hours.  Would  not 
nurse.  Had  had  repeated  injections  by  a  midwife  and  by  attending 
physician  with  no  avail.  Also  calomel.  Abdomen  now  somewhat 
distended  but  not  very  tense,  excepting  in  region  of  ascending  and 
transverse  colon,  especially  from  the  hepatic  flexure  to  the  middle 
line.  In  the  middle  of  the  epigastrium  or  slightly  to  the  right  of  it 
a  tumor  could  be  felt.  Pressure  upon  it  caused  tenesmus  and 
distress,  not  sharp  pain.  Diagnosis  intussusception  probably  at  the 
valve  of  Bauhin,  extending  as  far  as  transverse  colon.  Used  air 
and  water  pressure  (normal  saline  at  100  degrees  F.)  ;  under  light 
chloroform  anesthesia.  In  two  minutes  had  carried  pressure  to  three 
pounds.  Kept  this  up  three  minutes  more,  then  went  up  to  four 
pounds.  Kept  this  five  minutes.  Put  pressure  up  to  five  pounds  for 
two  minutes.  In  all,  the  pressure  was  on  twelve  minutes.  Pulse  ran 
to  180+.  Discontinued  pressure.  Manipulation  of  bowel  is  practi- 
cally impossible  after  the  pressure  is  on.  As  soon  as  anesthesia  and 
the  water  had  passed  off  babe  appeared  easy  and  comfortable. 
Tumor  gone.  He  went  to  sleep,  and  on  waking  cried  for  the  breast. 
No  vomiting,  straining  nor  pain.  Nine  hours  after,  fecal  stools 
began.     No  return  of  symptoms. 

Other  examples  could  be  cited,  but  these  are  sufficient  to  illus- 
trate the  method.  I  have  not  found  it  expedient,  as  Forest  advised, 
to  keep  the  pressure  up  for  an  hour,  or  anything  near  that.  In  feeble 
young  children  the  pressure  on  the  vena  cava  and  on  the  diaphragm 
impedes  the  return  circulation  and  the  respiration  markedly  after 
fifteen  to  twenty  minutes.  Older  children  can  stand  higher  pres- 
sure for  a  longer  time.  But  I  do  not  think  it  advisable  to  carry  the 
pressure  up  to  eight  or  nine  pounds  to  the  square  inch,  as  Forest 
advises,  if  the  invagination  does  not  yield  at  a  lower  strain.  Even 
if  the  colon  does  not  actually  rupture,  I  have  found  its  serous  coat 
cracked  at  seven  pounds,  and  this  in  intestines  not  weakened  by  in- 
flammation. It  gives  way  opposite  the  folds  which  divide  the 
saculi,  the  tendency  of  the  pressure  being  to  lengthen  as  well  as 
widen  the  tube  and  obliterate  the  transverse  folds.  This  it  seems  to 
me  might  be  sufficient  to  set  up  peritonitis ;  or  the  distension  might 
paralyze  the  gut. 

Forest  advocated  a  degree  of  pressure  that  risked  rupture  of  the 
gut  (provided  it  would  not  yield  at  a  lesser),  because  he  considered 
laparotomy  for  an  intussusception  irreducible  by  pressure  as  in- 
evitably fatal.  Fie  quotes  Treves'  tables  to  show  that  the  death 
rate  after  laparotomy,  even  though  the  invagination  was  easily  re- 
duced, was  43  per  cent.,  whereas  no  case  had  been  recorded  where 
the  patient  died  after  the  tumor  was  once  reduced  by  inflation  or 
injection.      Fle    says   the    statistics   of   Leichtenstcrn,   Treves   and 


588  SURGICAL  DISEASES    OF   CHILDREN 

Schram  show  that  the  death  rate  in  cases  in  which  the  invagination 
was  reduced  with  difficulty  or  was  irreducible  was  loo  per  cent. 
Therefore  he  advises  a  pressure  of  six  pounds  to  the  square  inch, 
and  if  this  fails  after  lengthened  trial  to  raise  the  pressure  to  seven 
or  eight  or  nine  pounds.  This  having  failed,  if  the  child  is  under 
two  years,  open  the  abdomen  and  resect  the  intestine.  The  child 
will  probably  die,  but  if  left  to  nature  the  case  is  hopeless.  If  the 
patient  is  between  two  and  five  years  and  injections  have  failed, 
the  chances  of  cure  by  sloughing  or  laparotomy  are  about  equal, 
and  the  surgeon  will  be  justified  in  following  either  course.  Lapa- 
rotomy will  mean  a  resection  or  enterotomy.  If  the  patient  is  over 
five  years  of  age  and  the  tumor  has  resisted  eight  or  nine  pounds  it  is 
irreducible;  and  he  quotes  statistics  to  prove  that  the  operation  of 
laparotomy  shows  a  greater  death  rate  than  cure  by  sloughing. 
"  Therefore  nature's  operation,  nearly  hopeless  as  it  is,  should  be 
preferred  to  laparotomy." 

Forest  had  perhaps  given  the  subject  more  careful  consideration 
than  any  other  writer  of  his  time,  and  one  must  admire  his  work  in 
systematizing  the  reduction  by  water  pressure  and  in  drawing  the 
attention  of  the  profession  to  the  necessity  of  precision  in  the  ap- 
plication of  the  treatment,  and  the  advantages  of  the  certain  and 
steady  pressure  of  the  fountain  syringe  as  compared  with  the  un- 
certain, intermittent,  irritating  effect  of  the  Davidson  syringe.  But 
the  status  of  abdominal  surgery  has  changed  so  much  since  the  time 
of  his  writing  that  the  advice  then  given  must  be  modified  accord- 
ingly. He  would  now  be  considered  ultra-conservative  as  regards 
laparotomy. 

But  now,  if  I  am  correct  in  my  judgment,  the  pendulum  has 
swung  too  far  the  other  way.  There  are  many  crying,  "  Waste  no 
time  on  injection  methods,  but  perform  laparotomy  at  once.  Sta- 
tistics could  now  be  brought  showing  lOO  per  cent,  of  recoveries 
after  laparotomy  for  intussusception."  Why,  then,  is  it  not  proven 
that  laparotomy  is  the  only  correct  treatment  ? 

Because,  for  one  reason,  the  cases  showing  loo  per  cent,  of 
recoveries  are  selected  cases  and  do  not  include  those  most  desper- 
ately in  need  of  operative  assistance.  And  because  by  laparotomy 
in  every  case  the  same  results  could  not  be  obtained  under  all  the 
circumstances  in  which  intussusception  must  be  met.  They  are  the 
statistics  of  skilled  operators  in  fully  equipped  hospitals  upon  se- 
letted  cases,  and  they  are  not  the  measure  of  what  can  be  done  by 
the  average  operator  and  under  unfavorable  conditions.  The  acute 
intussusception  is  an  emergency  which  must  be  promptly  met.  There 
is  no  comparison  with  elective  work  upon  chronic  cases  in  the 
hands  of  deliberately  selected  experts  in  a  well-equipped  hospital. 
Therefore  the  simple  methods  that  are  perfectly  efficient  in  the 


ESOPHAGUS,     STOMACH    AND     INTESTINES  589 

great  majority  of  cases,  and  can  be  applied  by  any  intellig^ent  prac- 
titioner anywhere  and  under  all  conditions  are  to  be  advocated  in 
the  first  instance,  and  emphasis  should  be  laid  upon  early  diagnosis, 
prompt  resort  to  aero-hydrostatic  methods  which  should  be  accu- 
rately and  thoroughly  carried  out ;  and  in  the  few  cases  in  which 
these  will  fail,  early  resort  to  laparotomy.  And  this  with  not  so 
gloomy  a  prognosis  as  was  probably  justified  when  Forest  wrote. 
No  surgeon  nowadays  feels  justified  in  abandoning  to  nature's 
methods  a  child  over  five  years  of  age,  with  intussusception  irre- 
ducible by  pressure  methods ;  and  none  would  consider  every  case 
of  the  kind  under  two  years  as  absolutely  hopeless.  It  is  my  opinion 
that  modern  results  indicate  the  rule  that  no  case  at  any  age  should 
be  laparotomized  without  a  correct  application  of  aero-hydrostatic 
method  of  reduction ;  and,  if  this  fails,  that  no  case  at  any  age 
but  should  be  subjected  to  laparotomy  within  the  hour. 

Laparotomy. — With  all  the  customary  antiseptic  preparation 
of  the  skin  with  the  room  at  a  temperature  of  80  degrees  F.  or  higher, 
and  the  patient  laid  upon  a  hot  water  bed  or  amply  surrounded  with 
artificial  heat,  the  abdomen  is  opened  in  the  middle  or  in  one  or  the 
other  semilunar  lines.  It  should  be  foreseen  that  plastic  work  upon 
the  intestines  is  likely  to  be  necessary  and  the  incision  planned 
accordingly.  In  the  majority  of  cases  it  will  be  made  in  the  middle 
line  or  the  right  semilunar  line  near  the  cecum.  Even  with  the 
abdomen  open  and  the  surgeon  holding  the  tumor  in  his  fingers 
it  may  not  be  easy  to  reduce  the  invagination.  There  should  be  no 
traction  with  the  idea  of  pulling  the  infolded  layers  apart.  One 
should  gently  press  or  squeeze  the  intussusceptum  upwards  out  of 
the  sheath.  If  reduction  is  effected  the  bowel  should  be  examined 
as  to  its  condition — whether  gangrenous,  or  injured,  and  dealt 
with  accordingly.  If  there  appears  a  tendency  for  invagination  to 
recur,  or  the  mesentery  is  unduly  long,  a  fold  shortening  the  mesen- 
tery should  be  taken  and  secured  with  a  few  stitches,  with  care 
not  to  interfere  with  the  blood  supply  of  the  bowel.  The  abdomen 
should  then  be  closed. 

If  the  intussusception  is  irreducible  and  the  child  is  in  too  low 
a  state  for  any  prolongation  of  the  operation,  a  fecal  fistula  may  be 
formed,  connecting  the  bowel  immediately  above  the  obstruction, 
with  an  incision  through  the  abdominal  wall.  If  the  original  in- 
cision is  rightly  placed  for  this  purpose,  a  knuckle  of  the  intestine 
is  drawn  out  of  the  wound  and  closely  sutured  to  the  peritoneum, 
and  then  to  the  external  parietes,  the  sutures  passing  only  through 
the  serous,  muscular  and  submucous  coats  of  the  intestine.  The  gut 
is  then  or  subsequently  incised,  thus  establishing  a  fecal  fistula, 
above  the  obstruction. 

Ellsworth  Eliot,  Jr.,   (Binnie)   suggests  that  the  intestine  near 


590 


SURGICAL   DISEASES    OF    CHILDREN 


the  lower  end  of  the  intussusceptum  be  brought  to  the  abdoraina] 
wound;  a  small  incision  through  the  gut  wall  be  made  near  this 
lower  end  of  the  tumor,  and  a  catheter  be  passed  through  this 
incision  and  through  the  canal  of  the  intussusceptum  into  the  gut 
above.  The  incision  is  to  be  sutured  to  the  abdominal  opening, 
making  a  fecal  fistula  below  the  obstruction,  preventing  increase  of 
the  intussusception,  and  providing  drainage  through  the  catheter. 


(Fig.  19; 


I  have  never  vet  tried  this  method. 


Fig.  195.  Eliot's  suggestion  for 
the  relief  of  intussusceptiox. 
The  gut  just  below  the  intussus- 
ception to  be  stitched  to  the  ab- 
dominal wall,  and  opened,  and  a 
soft  catheter  to  be  passed  through 
the  opening  of  abdominal  wall  and 
gut,  and  upward  through  the  canal 
of  the  intussusceptum  into  the  gut 
above. 


The  following  is  a  very 
ingenious  and  workmanlike 
method  of  excision  of  the  in- 
tussusceptum. (Figs.  196, 
197,  198.)  If  I  am  not  mis- 
taken it  was  originally  Bar- 
ker's operation.  The  entering 
portion  of  gut  is  sutured  to 
the  sheath  all  round  just  at 
the  point  of  entrance.  The 
gut  over  the  intussusceptum 
is  then  opened  (longitudin- 
ally) and  the  intussusceptum 
cut  oft  and  removed.  The  cut 
edges  of  the  two  layers  are 
then  united  by  continuous  sutures,  and  the  longitudinal  incision  in 
the  gut  is  closed  by  Lembert  sutures.  Thus  an  end  to  end  anas- 
tomosis is  effected,  and  the  strangulated  gut  removed.  This  entails 
less  loss  of  tissue  and  less  time  than  a  regular  enterectomy. 

Enterectomy  may  be  done,  but  it  is  badly  borne  by  children.  It 
will  prove  too  much  for  a  young  child.  If  it  must  be  done,  the 
anastomosis  should  be  made  with  the  ]\Iurphy  button.  Circular 
enterorrhaphy  or  lateral  anastomosis  take  too  long. 

FOREIGN  BODY  IN  STOMACH,  INTESTINE  OR  RECTUM 

A  foreign  body  in  the  stomach  or  intestines  may  be  almost 
any  imaginable  object  not  too  large  for  a  child  to  swallow.  Pins, 
needles,  buttons,  bullets,  coins,  fruit-stones  or  seeds,  strings  or 
threads  are  among  the  most  ordinary.  Almost  any  object  that  can 
be  swallowed  will  find  its  way  safely  through  the  alimentary  canal, 
yet  some  are  of  such  a  shape  that  by  change  of  position  they  may 
lodge  at  the  pylorus  or  ileo-cecal  valve,  while  other  objects  may  by 
moisture  become  swollen  to  such  a  size  as  cannot  pass.  Strings, 
fruit  seeds,  fibrous  material  and  feces  may  collect  in  a  large  mass 
which  cannot  pass  onward,  causes  an  obstruction  by  its  bulk  or  sets 
up  an  inflammation  with  consequent  swelling,  and  so  produces 
obstruction.     There  are  well-authenticated  cases  of  intestinal  ob- 


ESOPHAGUS,    STOMACH    AND    INTESTINES 


591 


struction  caused  by  masses  of  Itimbricoid  worms.  Needles  swal- 
lowed may  work  their  way  through  the  coats  of  stomach  or  intes- 
tines  and   appear   in   some 


distant  part  of  the  body. 
Foreign  body  may  be 
found  in  the  rectum.  It 
may  have  been  swallowed, 
or  it  may  have  been  intro- 
duced per  anum  by  the 
patient  himself  or  by  mis- 
chievous companions. 

Symptoms  of  foreign 
body  are  sometimes  very 
indefinite  and  puzzling.  I 
recall  the  case  of  a  child 
with  symptoms  of  a  mild 
gastric  catarrh  in  which 
vomiting,  though  not  fre- 
quent,   was    persistent    for 


Fig.  196.  Excision  of  intussusceptum. 
The  entering  portion  is  sutured  to  the 
intussuscipiens  at  the  neck.  The  en- 
sheathing  layer  is  cut  open  longi- 
tudinally and  the  intussusceptum  ex- 
cised. After  Guibe.  See  also  Fig.  197. 


Fig.  197.  Excision  of  intussus- 
ceptum. The  intussusceptum  is 
removed  and  its  cut  edges  are 
united  by  suture.  After  Guibe. 
See    also    Fig.    198. 


Fig.  198.  Excision  of  in- 
tussusceptum. The  in- 
cision in  the  ensheath- 
ing  layer  is  carefully 
closed,  by  two  rows,  or 
preferably  by  Lembert 
sutures.     After    Guibe. 


several   days   until,  finally,  a  flat  piece   of  beef-bone  about   three- 
fourths  of  an  inch  square  was  vomited  up  and  the  trouble  ended. 


592  SURGICAL   DISEASES    OF    CEIILDREX 

Occasionally  there  is  only  discomfort  and  distress  in  tlie  abdo- 
men with  colicky  pains  and  perhaps  nausea  as  the  foreign  body 
is  gradually  worked  along  down  the  canal,  lodging  temporarily 
here  and  there.  A  foreign  body  may  be  days  or  weeks  in  travers- 
ing the  alimentary  canal.  One  case  of  a  boy  upon  whom  I  operated 
for  suppurative  appendicitis  failed  to  become  quite  comfortable,  al- 
though the  appendix  was  removed,  the  wound  healed  and  to  all 
appearances  he  should  have  been  well.  He  was  kept  in  hospital 
three  weeks  after  operation  on  account  of  indefinite  colicky  pains 
and  abdominal  uneasiness  for  which  I  could  discover  no  cause. 
Finally  he  developed  tenesmus  and  pain  in  the  rectum,  and  digital 
exploration  revealed  the  presence  there  of  a  strong  fish-bone  curved 
somewhat  in  the  shape  of  a  fish-hook.  It  was  removed  and  he  was 
quite  well.  He  had  not  eaten  fish  during  his  stay  in  the  hospital, 
and  his  mother  was  quite  sure  he  had  eaten  no  fish  for  several 
weeks  before  he  entered.  If  a  foreign  body  becomes  lodged,  as  it 
is  most  apt  to  do.  just  above  the  ileo-cecal  valve,  and  causes  in- 
flammation, or  is  of  a  size  and  shape  to  mechanically  obstruct  the 
canal,  vomiting,  distension  of  the  abdomen  and  peritonitis  ensue. 
If  not  relieved,  gangrene  of  the  bowel  and  death  will  probably  result. 

Diagnosis. — The  diagnosis  may  be  difficult  unless  the  histor}'- 
of  swallowing  a  foreign  body  is  definite.  The  very  indefiniteness 
and  shifting  character  of  the  symptoms  should  make  one  suspicious. 
Occasionally  a  foreign  body  can  be  felt  if  the  abdomen  is  relaxed 
either  with  or  without  anesthesia.  The  Roentgen  ray  renders  valu- 
able ser^nce  if  the  foreign  body  is  impervious  to  it.  Gastroscopy 
by  the  direct  method,  as  described  by  Jackson,  may  discover  it  if 
in  the  stomach.  The  rectum  should  always  be  explored  with  the 
finger,  which  may  detect  and  locate  the  foreign  body  there.  Foreign 
body  in  the  rectum  may  cause  pain  and  tenesmus  with  passage  of 
mucus  and  sometimes  bloody  stools.  Suppuration  or  even  abscess 
may  result  from  the  irritation  or  wound  produced. 

Treatment. — When  a  child  is  known  to  have  swallowed  a  foreign 
body,  almost  invariably  the  mother  or  nurse  gives  a  laxative  and 
prides  herself  on  her  presence  of  mind  in  so  doing.  The  laxative 
should  have  been  withheld.  Its  administration  is  most  unwise.  To 
empty  the  bowel  exposes  its  mucous  lining  to  any  rough  or  sharp 
surface  upon  the  foreign  body  with  which  the  active  peristalsis, 
excited  by  the  laxative,  brings  it  in  forcible  contact.  A  better 
plan  is  to  administer  an  abundance  of  bulky,  constipating  food,  such 
as  potatoes,  rice,  cornstarch,  or  bread,  which  forms  large,  firm 
masses  likely  to  encase  the  foreign  body,  and  distend  the  intestine 
as  they  are  moved  slowly  and  safely  along.  If  the  foreign  body 
lodge  and  cause  intestinal  obstruction,  laparotomy  will  be  neces- 
sary.    (See  Section  on  Operation  for  Intestinal  Obstruction.) 


ESOPHAGUS,    STOMACH    AND    INTESTINES  593 

It  is  often  necessary  to  anesthetize  a  patient  to  remove  a 
foreign  body  from  the  rectum.  Careful  exploration  with  the  linger 
will  usually  reveal  the  shape  and  situation  of  the  offending  article. 
A  speculum  or  retractors  may  be  necessary  or  the  sphincter  may 
have  to  be  divulsed.  The  finger,  or  forceps  or  suitable  instrument 
will  then  effect  the  removal.  Ulcerations  or  granulations  will 
then  be  touched  with  hydrogen  peroxide  or  silver  nitrate,  and  olive 
oil  poured  into  the  rectum.  This  dressing  may  have  to  be  repeated. 
The  rectum  should  be  cleansed  by  irrigation  daily.  The  diet  should 
be  regulated,  and  the  patient  kept  quiet.  As  healing  progresses 
watch  should  be  kept  for  stricture,  and  if  necessary  the  rectum 
dilated  with  the  finger  or  bougies. 

FECAL  IMPACTION 

It  is  not  uncommon  for  impaction  of  feces  to  cause  dangerous 
obstruction  of  the  intestinal  tract.  The  cecum,  the  sigmoid  flexure, 
and  especially  the  rectum  are  favorite  sites  for  impaction.  One  has 
several  times  been  obliged  to  remove  piecemeal  from  the  rectum 
quantities  of  scybalse  mixed  with  prune-stones  or  fruit  seeds  and 
skins  and  the  like,  packed  together  as  hard  as  putty  and  immovable 
until  broken  up.  The  symptoms  are  those  of  obstruction  coming  on 
slowly,  and  sometimes  with  a  demonstrable  tumefaction  of  a  doughy 
consistency  and  movable,  in  some  part  of  the  abdomen.  I  have  seen 
it  stated  that  the  tumor  of  fecal  impaction  could  be  differentiated 
from  that  of  intussusception  by  its  usually  being  located  in  the 
right  side,  while  intussusception  is  usually  on  the  left  side.  This 
statement  I  consider  misguiding,  having  felt  fecal  impaction  on  the 
left  side  or  in  the  sigmoid  region  as  well  as  on  the  right,  and  in- 
tussusception on  the  right  side  as  well  as  on  the  left.  The  character 
of  the  tumefaction  is  of  more  diagnostic  value  than  the  situation. 
(See  "  Tumor  "  in  the  section  on  Intussusception.) 

Treatment. — Fecal  impaction  can  generally  be  overcome  by 
repeated  copious  enemata  aided  by  gentle  massage,  and  careful  use 
of  laxatives,  usually  salines  in  broken  doses.  Purgatives  are  for- 
bidden. 

ENTEROLITES 

Intestinal  concretions,  of  a  sufficiently  stony  character  to  be 
called  enterolites,  are  certainly  rare  in  this  country.  They  are  said 
to  consist  in  some  instances  of  phosphatic  salts,  together  with 
cholesterin  and  mucus ;  or  of  chalk  mixture,  or  magnesium  car- 
bonate, or  the  like  used  as  medicine.  They  should  be  treated  as 
just  described  for  fecal  impaction  or  foreign  body. 


594  SURGICAL   DISEASES    OF    CHILDREN 

VOLVULUS 

Under  this  name  are  included  three  forms  of  obstruction  or 
partial  obstruction  of  the  intestines.  First,  a  loop  of  intestine  may 
be  twisted  upon  its  mesentery  as  an  axis.  Secondly,  a  portion  of 
intestine  may  be  twisted  upon  itself  as  an  axis  so  as  to  occlude  its 
lumen.  Thirdly,  two  separate  loops  of  intestine  are  intertwined  so 
as  to  obstruct  the  lumen  of  one  or  both  loops. 

Volvulus  is  not  a  common  accident  of  early  life.  Treves  men- 
tions a  case  reported  by  Cripps  of  congenital  volvulus  of  the  ileum, 
and  cases  are  on  record  of  this  condition  in  various  portions  of  the 
small  intestine,  or  in  the  cecum  or  colon,  in  infants  and  children. 
But  volvulus  more  frequently  occurs  in  the  sigmoid  flexure  w^hen 
its  mesentery  is  long  and  loose. 

Symptoms. — The  symptoms  are  pain,  paroxysmal  at  first,  but 
becoming  continuous  with  distension  of  the  bowel.  Peritonitis 
usually  supervenes  promptly.  Tenderness  is  localized  early  in  the 
case,  l3Ut  soon  becomes  general  with  the  spread  of  the  peritonitis. 
Distension  of  the  intestines  is  apt  to  be  irregular  at  first,  upon  one 
or  the  other  portion  of  the  abdomen,  according  to  location  of  the 
twist.  The  abdominal  walls  are  flaccid  at  first,  until  the  distension 
of  the  bowels  becomes  general,  and  when  peritonitis  supervenes  they 
become  rigid.  Vomiting  is  present,  but  is  not  so  prompt  or  severe 
a  symptom  as  in  strangulation  by  bands.  Fecal  vomiting  is  unusual, 
but  eructations  are  common.  Constipation  is  the  rule.  The  tem- 
perature is  at  or  below  normal  and  may  remain  so  until  the  fatal 
termination.  The  pulse  is  rapid  and  small.  Tenesmus  is  a  frequent 
and  distressing  symptom  in  volvulus  of  the  sigmoid  flexure.  Sup- 
pression of  urine  is  not  as  marked  a  symptom  as  has  been  sup- 
posed, nor  as  marked  as  in  obstruction  by  bands.  When  occurring 
it  seems  to  depend  somewhat  on  reflex  causes,  as  the  urine  in- 
creases under  the  use  of  opium  and  relief  of  pain  and  tenesmus. 
There  is  no  bloody  stool  nor  tumor,  as  in  intussusception. 

Treatment. — Treatment  consists  in  laparotomy,  with  untwist- 
ing or  disentangling  of  the  intestine.  This  is  not  always  easily 
accomplished  even  after  the  abdomen  is  opened;  and  often  there 
is  a  tendency  for  the  twist  to  recur.  This  must  be  prevented  by 
folding  up  the  elongated  mesentery  and  holding  it  in  the  shortened 
position  with  sutures,  without  interfering  with  its  circulation.  If 
gangrene  threatens  in  the  twisted  loop  of  gut,  enterectomy  with 
anastomosis  should  be  done.  If  the  child  is  too  young  or  too 
feeble  to  withstand  so  extensive  and  prolonged  an  operation  the 
gangrenous  portion  of  gut  may  perhaps  be  brought  out  at  the  in- 
cision and  excised  and  an  artificial  anus  establishedo 


ESOPHAGUS,    STOMACH    AND    INTESTINES  595 

INTERNAL    STRANGULATION 

Like  volvulus,  internal  strangulation  is  more  often  talked  about 
than  met  with,  yet  it  does  occasionally  occur,  in  one  of  its  numer- 
ous varieties.  It  is  caused  by  bands  of  adhesions  resulting  from 
previous  peritonitis,  or  by  omphalo-mesenteric  vessels,  by  a  Meckel's 
or  other  diverticulum,  by  an  adherent  or  coiled  appendix  vermi- 
formis,  or  by  a  hole  in  the  mesentery  or  omentum.     (See  Hernia.) 

SyDiptoms. — The  symptoms  are  pain,  which  is  usually  referred 
to  the  umbilical  region.  The  pain  comes  suddenly  and  is  severe 
and  continuous.  Tenderness  is  not  marked  until  after  peritonitis 
supervenes.  Vomiting  is  an  early  and  marked  symptom.  It  be- 
comes stercoraceous  after  several  days.  Thirst  is  distressing.  Sup- 
pression of  urine  is  usually  noted.  Constipation  is  the  rule  after 
the  intestinal  contents  below  the  obstruction  have  been  discharged. 
Shock,  and  sometimes  collapse,  with  subnormal  temperature,  fol- 
low the  accident.  Absence  of  fever  does  not  negative  peritonitis. 
The  abdominal  walls  are  at  first  relaxed,  but  afterward  distended, 
and  with  peritonitis  they  become  rigid. 

Treatment  is  laparotomy  with  release  of  the  strangulated  gut, 
by  disentangling  or  withdrawing  it  or  by  cutting  bands  after 
securing  them  doubly  with  ligatures. 

Operation  for  Obstruction  of  the  Bozvels. — The  operating 
room  should  be  well  lighted,  and  warmed  to  80  degrees  F.  or  a 
higher  temperature.  The  patient  should  be  laid  upon  a  hot-water 
bed,  or  be  well  wrapped  in  cotton  and  surrounded  with  hot-water 
bottles.  The  vomiting  and  the  abdominal  distension  can  often 
be  relieved  by  lavage  of  the  stomach  with  warm  sterile  water.  The 
bladder  should  be  emptied  by  catheter.  Chloroform  or  chloro- 
form and  oxygen  are  usually  preferred  as  the  anesthetic.  The 
instruments  required  are  scalpel  and  scissors,  two  pairs  tissue  for- 
ceps, half  a  dozen  fine-pointed  hemostats,  two  or  three  hemostats 
for  sponge  holders,  a  grooved  director,  two  intestinal  clamps, 
ordinary  needles,  round  needles  for  the  gut,  needle  holder,  fine  silk 
and  fine  catgut,  medium  catgut,  and  silkworm  gut,  one  or  two 
Murphy  buttons.  The  instrujnents  must  be  thoroughly  sterilized 
by  boiling  and  the  sutures  reliably  aseptic.  The  hands  of  operator 
and  assistants  must  be  rendered  aseptic  by  thorough  scrubbing 
with  green  soap  and  hot  water,  the  nails  cleaned,  then  washed 
again,  rinsed,  and  washed  in  bichloride  solution,  i  to  2000,  then 
covered  with  rubber  gloves  that  have  just  been  boiled.  The  skin  of 
the  entire  abdomen  should  be  prepared  by  scrubbing  with  green 
soap,  hot  water  and  gauze  or  flannel.  This  being  rinsed  oflf  with 
sterile  water  is  followed  by  ether  or  alcohol,  and  then  with  solu- 
tion   of    mercuric    bichloride    i    to    3000   or    i    to    4000.      Sterile 


596  SURGICAL  DISEASES    OF   CHILDREN 

towels,  dry  and  warm,  should  be  used  beneath  the  patient  and 
to  surround  the  field  of  operation.  If  possible  the  situation  of  the 
obstruction  should  be  ascertained  by  localizing  the  pain,  tender- 
ness, tympanites,  tumefaction,  dullness,  or  by  the  X-ray.  If  located, 
the  incision  may  be  made  upon  it.  If  its  location  is  unknown  one 
is  directed  to  make  the  incision  in  the  median  line  below  the  um- 
bilicus. But  in  the  young  child  the  umbilicus  is  relatively  nearer 
to  the  OS  pubis,  and  the  bladder  is  apt  to  project  higher  than  in 
the  adult.  Room  is  needed  for  the  introduction  of  two  fingers  at 
least.  It  may  be  difficult  to  secure  an  incision  of  sufficient  length 
between  bladder  and  umbilicus,  in  which  case  it  must  be  carried 
higher,  usually  to  the  left  of  the  umbilicus.  When  the  incision 
is  carried  down  to  the  peritoneum  the  latter  should  be  carefully 
lifted  between  two  pairs  of  tissue  forceps  and  cautiously  incised, 
as  the  distended  bowel  generally  presses  closely  beneath.  The  in- 
testine should  not  be  allowed  to  escape  from  the  incision,  but  re- 
strained by  a  large,  flat  gauze  sponge  wrung  from  hot  water. 

Finding  the  point  of  obstruction  often  proves  to  be  no  easy 
task,  unless  its  whereabouts  have  been  ascertained  beforehand 
by  locating  tumor,  dullness  or  irregular  distension.  We  are  usually 
directed  to  pass  one  or  two  fingers  in  through  the  incision  and  pal- 
pate the  cecum  or  region  of  the  ileo-cecal  valve,  which  is  fre- 
quently the  point  of  obstruction.  If  the  cecum  be  distended,  feel 
along  down  the  colon,  as  the  obstruction  must  be  lower  down. 
But  if  the  cecum  be  not  distended  the  obstruction  must  be  higher 
up,  in  the  small  intestine.  We  are  now  directed  to  find  a  loop  of 
intestine  that  is  not  distended ;  examine  its  mesentery  at  its  attach- 
ment to  the  spine  to  find  which  is  its  right  layer,  for  the  right  layer 
is  also  the  upper  layer.  That  portion  of  the  upper  layer  which  goes 
to  the  left  is  the  one  leading  toward  the  stomach,  and  if  followed 
will  lead  to  the  obstruction.  But  these  directions  are  not  easily 
followed  when  the  abdomen  is  tightly  distended  with  intestines 
inflated  with  gas,  and  forcing  themselves  out  through  the  incision. 
Exposure  of  the  intestines  outside  the  abdominal  walls  greatly 
increases  the  shock  of  the  operation,  especially  in  children.  Ex- 
tensive or  prolonged  manipulation  of  the  intestines  has  the  same 
efTect.  Mr.  Greig  Smith  gives  some  advice  covering  this  point 
which  should  always  be  tried  in  children,  before  ever  a  finger  is 
passed  into  the  abdominal  cavity.  He  observes  that  the  most  dis- 
tended coils  always  rise  to  the  surface,  ^  and  that  as  the  greater 
number  of  coils  of  the  intestines  pass  within  three  inches  of  the  um- 
bilicus, it  is  probable  the  most  dilated  coils  will  be  or  can  be 
brought  within  sight  at  the  incision.  One  should  very  gently  move 
the  distended  coils  from  side  to  side  and  up  and  down,  and  select 
the  most  distended  one  which  will  at  the  same  time  prove  to  be 


ESOPHAGUS,    STOMACH    AND    INTESTINES  597 

the  most  congested  one.  By  following  this  coil  in  the  direction  of 
increasing  distension  and  congestion  one  is  led  to  the  obstruction. 
If  this  method  fail,  Smith  recommends  to  let  the  most  distended 
coil  escape  from  the  belly.  One  end  of  the  coil  escapes  less  readily 
than  the  other  and  is  most  congested.  This  end  leads  toward  the 
obstruction.  (Greig  Smith,  Binnie.)  In  some  cases  it  may  be 
necessary  to  relieve  the  excessive  distension  by  incising  the  intes- 
tine to  allow  the  escape  of  its  contents.  To  do  this  a  badly  dis- 
tended loop  is  brought  outside  the  abdomen,  packed  round  with 
hot  moist  gauze  sponges  and  a  small  incision  made  in  a  longi- 
tudinal direction  at  a  point  farthest  from  the  mesentery.  The 
contents  having  escaped,  the  incision  is  securely  closed  with  Lem- 
bert  sutures,  the  gut  rinsed  off  clean  with  hot  sterile  normal  salt 
water,  and  returned  to  the  abdomen.  To  remove  the  rubber  gloves 
and  put  on  a  fresh  sterile  pair  at  this  point  is  advisable  if  it  be 
done  quickly.  But  if  such  incision  and  emptying  of  bowel  can  be 
avoided  it  is  far  better  to  do  so.  If  the  point  of  obstruction  be 
found  it  should  be  dealt  with  according  to  its  character,  a  volvulus 
should  be  untwisted  or  disentangled,  strangulating  bands  should 
be  ligated  in  two  places  and  cut  between  the  ligatures,  a  foreign 
body  should  be  removed  through  a  longitudinal  incision  in  the 
intestine  which  is  afterward  closed  with  Lembert  sutures.  Before 
opening  an  intestine  it  should  be  brought  outside  the  abdomen 
and  packed  round  with  moist  hot  gauze  sponges.  The  special 
manner  of  dealing  with  intussusception  will  be  found  in  the  Sec- 
tion on  that  subject.  If  it  be  found  that  the  cause  of  the  obstruc- 
tion cannot  be  removed  or  if  the  child  is  very  much  shocked  or 
exhausted,  one  should  not  think  of  attempting  any  extensive  oper- 
ation, but  rapidly  make  a  fecal  fistula  above  the  obstruction,  close 
the  abdominal  incision  and  apply  heat  and  stimulants  as  directed  to 
combat  shock. 


CHAPTER  XXII 

HERNIA 

Its  Causes,  Frequency  and  Varieties — Irreducible  Hernia — 
Strangulated  Hernia — Diaphragmatic  Hernia — Ventral 
Hernia — Umbilical  Hernia — Inguinal  Hernia — Femoral 
Hernia — Lumbar  Hernia — Vaginal  Hernia — Traumatic 
and  Post-Operative  and  Relapsed  Hernia. 

ITS  CAUSES,  FREQUENCY  AND  VARIETIES 

Hernia  may  be  due  to  a  fault  in  development  which  leaves 
an  opening-  or  a  very  weak  point  in  the  muscular  and  aponeurotic 
layers  that  bound  the  abdominal  cavity.  Or  the  supporting  walls 
in  a  feeble  individual  may  be  weak  throughout,  or  be  weakened  by 
illness  or  malnutrition  or  faulty  innervation.  Added  to  one  or 
more  of  these  causes  there  may  be  the  thinning  and  fraying  out 
and  paralyzing  by  overstretching  that  comes  with  continuous 
distension  by  overloaded  stomach  and  intestines  inflated  with 
gases.  The  adipose  tissue  that  should  help  to  fill  interstices  and 
to  cushion  the  visceral  supports  may  have  always  been  wanting 
or  it  may  have  been  removed  by  wasting  disease.  Yet  excessive 
obesity,  or  a  sudden  reduction  of  obesity,  such  as  occasions  hernia 
in  adults,  does  not  often  obtain  in  children.  Intra-abdominal  ten- 
sion may  have  been  increased  by  the  tenesmus  of  constipation  or 
of  diarrhea,  of  rectal  polypus,  or  vesical  calculus,  or  a  narrow 
preputial  or  urethral  orifice,  or  a  cough  either  long  continued  or 
spasmodic  and  violent,  or  by  persistent  crying,  or  by  the  use  of  a 
tight  bellyband,  or  a  truss  band  worn  for  umbilical  hernia.  Tak- 
ing all  these  facts  into  consideration  it  is  not  sufficient  when  one 
encounters  a  hernia  to  merely  announce  its  name,  or  perhaps  to 
go  so  far  as  to  specify  what  variety  it  represents  and  then  direct 
the  parents  to  a  truss  dealer,  or  turn  to  the  calendar  for  the  next 
clinic  day  when  it  will  be  convenient  to  operate.  There  are  a 
great  many  things  to  be  considered  about  the  hernia  before  the 
course  of  procedure  is  decided  upon.  For  instance,  what  caused 
and  what  factors  are  perpetuating  the  hernia,  its  possible  com- 
plications, and  its  probable  results  if  treated  by  trussing,  or  by 
operation;  also  the  type,  the  fitting  and  the  management  of  the 

598 


HERNIA  599 

truss,  and  the  best  time  and  method  for  the  operation  if  such  a 
procedure  is  necessary. 

All  the  common  varieties  of  hernise  found  in  the  adult,  named 
from  their  situation,  are  found  in  children — diaphragmatic,  ven- 
tral, lumbar,  umbilical,  inguinal,  femoral ;  and  some  sub-varieties 
belonging  especially  to  children,  such  as  the  congenital,  the  funic- 
ular, the  infantile,  the  encysted  herniae.  But  the  relative  fre- 
quency of  such  varieties  is  quite  different  in  early  when  compared 
with  adult  life.  Thus  umbilical  hernia  is  far  more  common  in 
childhood,  and  femoral  hernia  comparatively  rare.  Obturator, 
perineal,  and  ischiatic  hernise  are  not  found  in  children.  The  classi- 
fication according  to  the  organ  or  viscus  protruding,  as  h.epato- 
cele,  epiplocele,  enterocele,  cystocele,  and  the  like,  would  show  a 
different  distribution  in  children ;  for  it  is  comparatively  seldom 
that  the  sac  contains  anything  but  intestine,  the  omentum  being 
but  slightly  developed,  and  the  bladder  and  vagina  not  yet  having 
been  subjected  to  causes  that  in  later  life  produce  relaxation  and 
protrusion.  However,  not  only  small  or  large  intestine,  sigmoid, 
cecum,  or  appendix,  but  a  portion  of  liver  or  of  bladder,  or  an 
ovary  or  the  uterus,  or  a  testicle  attached  to  a  loop  of  intestine, 
may  be  found  in  the  child's  hernia.  (See  Fig.  213.)  Naturally 
the  proportion  of  the  congenital  variety  is  large  and  of  the  ac- 
quired is  small  in  the  child  as  compared  with  the  adult. 

IRREDUCIBLE  HERNIA 

Hernia  in  a  child  may  be  irreducible,  due  to  the  same  causes 
as  in  the  adult.  But  it  is  less  common  in  the  child,  because  the 
hernia  has  not  existed  sufficiently  long  to  become  adherent  in  the 
abnormal  situation.  But  hernia  may  become  obstructed  or  incar- 
cerated by  massing  of  its  contents. 

STRANGULATED    HERNIA 

Strangulation  occurs  seldom  in  children,  in  comparison  with 
the  whole  number  of  hernise.  Yet  it  occurs  sufficiently  often  to 
emphasize  the  necessity  of  never  allowing  a  hernia  to  remain 
unreduced. 

Symptoms  of  strangulation  are  nausea,  vomiting,  constipation, 
tenesmus,  dragging  sensations  in  the  hypogastrium,  local  pain,  ten- 
derness, swelling,  and  tension  in  the  hernia,  fever  and  later  sub- 
normal temperature ;  pulse  hard  and  quick,  later  wiry,  small  and 
weak  and  more  rapid.  The  face  is  either  flushed  with  fever  or 
pallid  as  in  shock,  anxious  and  drawn.  The  constriction,  if  un- 
relieved, causes  not  only  congestion  and  swelling,  but  inflammation 
and  cfancfrene.     If  the  constriction  be  absolute  the  whole  of  the 


6oo  SURGICAL   DISEASES    OF   CHILDREN 

extruded  gut  will  become  gangrenous;  but  in  less  complete  stran- 
gulation death  of  the  tissue  may  occur  only  at  the  point  of  con- 
striction. In  either  case  perforation  may  occur  and  cause  violent 
septic  peritonitis. 

Diagnosis. — The  diagnosis  is  easy  unless  the  hernia  be  of  the 
diaphragmatic  or  vaginal  varieties.  Symptoms  of  obstruction  of 
the  bowels  in  the  presence  of  a  demonstrable  hernia  should  lead 
to  prompt  treatment  of  the  hernia  as  strangulated. 

Treatment. — If  the  strangulation  has  not  existed  more  than  a 
few  hours  and  the  patient  is  in  fair  condition,  an  anesthetic  should 
be  administered  and  the  patient  placed  in  such  a  position  as  to  relax 
the  muscles  at  the  hernial  site,  and  secure  the  aid  of  gravity  in 
drawing  the  hernia  into  th^e  abdominal  cavity.  The  taxis  should 
then  be  tried  with  the  utmost  gentleness.  The  tumor  is  pressed  upon 
slowly  and  persistently  for  some  minutes  so  as  to  squeeze  some  of 
its  fluid  or  gaseous  contents  into  the  abdominal  cavity,  or  some  of 
the  swelling  out  of  its  tissues.  An  attempt  is  made  to  lift  it  away 
from  the  constriction  as  if  drawing  it  out  'of  the  hernial  opening. 
With  the  ends  of  the  fingers  of  the  other  hand  the  neck  of  the  sac 
is  pushed  from  sid.e  to  side  and  palpated.  Perhaps  the  hernia  will 
gurgle  and  slacken  and  slip  away  into  the  abdomen.  If  these 
maneuvers  do  not  succeed  in  reducing  it,  preparation  should  at 
once  be  made  for  operation.  If  the  symptoms  of  strangulation 
had  been  present  twenty-four  or  forty-eight  hours  before  the  pa- 
tient is  first  seen,  or  he  be  in  a  bad  condition  with  a  weakening 
pulse,  a  pinched  face  and  a  dry  tongue,  no  time  should  be  lost  with 
the  taxis ;  the  operation  is  to  be  done  at  once.  If  the  patient  is 
first  seen  where  no  anesthetic  is  at  hand,  or  if  there  must  be  delay 
before  the  operation  can  be  performed,  opium,  or  better,  a  hyper- 
dermic  of  morphia  or  of  codeine  phosphate  should  be  given;  the 
patient  should  be  placed  in  the  most  favorable  position  for  reduc- 
tion and  propped  or  suspended  in  that  position,  with  an  icebag, 
comfortably  cold,  pressing  upon  the  hernia.  If  reduction  does  not 
take  place  while  preparations  are  in  progress  the  taxis  or  the  opera- 
tion can  then  be  done.  If  the  patient's  temperature  is  subnormal, 
heat  and  stimulants  should  be  used. 

Operation  for  Strangulated  Hernia. — No  degree  of  urgency 
should  induce  one  to  neglect  all  the  antiseptic  precautions  suit- 
able in  an  abdominal  operation.  (See  Section  on  Operations  for 
Intestinal  Obstruction  for  the  preparation  of  the  patient;  and 
for  the  instruments  and  articles  needed.)  In  former  years  herniot- 
omy was  expected  only  to  relieve  the  strangulation,  but  usually 
nowadays  the  wound  is  closed  in  such  a  manner  that  the  hernia 
cannot  occur  again,  so  that  the  incision  is  made  with  that  end  in 
view.    Most  frequently  the  constriction  is  in  the  ring  and  not  in  the 


HERNIA  6oi 

sac.  In  inguinal  hernia  it  is  generally  the  external  ring  that 
strangulates.  Often  the  sac  will  be  opened  whether  it  was  intended 
to  open  it  or  not,  for  it  is  very  thin  and  closely  blended  with  the 
fascia.  When  the  sac  is  nicked  and  opened  there  is  a  fluid  within, 
pale  yellow,  if  the  case  is  early  and  the  bowel  in  good  condition ; 
dark  brown  if  the  case  is  more  advanced,  but  one  is  not  appre- 
hensive if  the  fluid  is  clear.  If  the  fluid  is  turbid  and  blackish  one 
has  fears,  for  the  bowel  will  be  found  inflamed  and  edematous  at 
least,  purple  and  mottled,  and  perhaps  worse.  But  if  lymph  flakes 
and  pus  and  maybe  blood  clots  flow  out  with  the  fluid  from  the  sac, 
gangrene  is  near  at  hand.  Perhaps  already  the  intestine  is  dull 
and  sodden,  black  or  ashy  and  sloughing.  If  the  intestine  or  other 
strangulated  organ  or  viscus  is  sound,  or  if  its  circulation  can  be 
restored,  the  constriction  is  relieved  and  it  is  allowed  to  slip  back 
into  the  abdomen.  A  great  point  is  made  by  students  to  remember 
in  which  direction  one  should  cut  in  relieving  a  hernial  constric- 
tion. It  is  better  to  do  no  cutting  at  all  in  the  dark.  Sometimes, 
merely  lifting  the  constricting  ring  with  a  blunt  dissector  or  nick- 
ing its  edge  if  necessary  will  suffice.  If  cutting  is  necessary  it  is 
better  to  cut  down  with  knife  or  scissors  so  as  to  see  what  is  being 
cut.  After  the  hernia  is  reduced  the  opening  is  securely  closed 
as  in  the  radical  operation  for  hernia.  If  protruded  gut  is  perfor- 
ated or  not  viable  one  has  the  choice  of  resection  or  temporary 
artificial  anus.  An  older  child  in  good  condition  for  operation  might 
endure  resection  and  anastomosis.  A  young  or  exhausted  child 
would  not;  and  it  would  be  better  to  draw  out  the  intestine  until 
sound  tissue  appears,  attach  the  open  ends  of  the  gut  into  the 
hernial  opening  and  save  the  patient's  life.  The  continuity  of  the 
intestinal  lumen  can  be  restored  by  one  of  various  operations  later 
when  the  patient  is  in  condition. 

DIAPHRAGMATIC  HERNIA 

This  may  be  congenital,  ordinary  or  traumatic.  In  either  form 
it  is  extremely  rare.  In  the  congenital  form  the  deficiency  of  the 
diaphragm  is  usually  upon  the  left  side.  The  opening  may  be  small 
so  that  only  a  limited  protrusion  of  abdominal  contents  occurs ;  or 
so  large  as  to  occupy  nearly  the  entire  chest  cavity,  and  by  prevent- 
ing expansion  or  even  development  of  the  lungs,  be  incompatible 
with  extra-uterine  life.  Such  a  case  is  illustrated  in  Figs.  199  and 
200,  drawn  at  the  autopsy  on  a  full-term  seven-pound  girl  baby 
which  cried  twice  after  birth  and  died  in  twenty  minutes.  In  the 
embryo  the  cavity  of  the  body  is  not  divided  into  thorax  and  ab- 
domen until  their  organs,  especially  the  liver,  have  attained  a  con- 
siderable degree  of  development.  The  internal  layer  of  the  blas- 
toderm has  closed  up  to  form  a  gastro-intestinal  canal.    It  assumes 


602 


SURGICAL   DISEASES    OF   CHILDREN 


a  tubular  form  and  then  the  upper  end  of  the  tube  expands  to  form 
the  stomach,  which  hes  in  the  upper  portion  of  the  body  cavity, 
near,  but  not  connected  with,  the  cavity  which  will  become  the 


OS  Jiub'is 

Fig.  199.     Case  of  Congenital  Diaphragmatic  Hernia. 

pharynx.  The  liver  has  budded  out  from  the  intestinal  canal  and  at 
one  month  weighs  one-quarter  as  much  as  the  whole  embryon 
and  fills  most  of  the  entire  cavity.  The 
esophagus  begins  to  appear  as  a  short  tube 
which  by  and  by  will  open  through  into  the 
stomach  below  and  the  pharynx  above.  The 
lungs  bud  out  from  the  sides  of  the  esopha- 
gus, which  later  partitions  off  a  portion  of 
its  tube  for  the  trachea.  Still  there  is  no 
division  of  the  cavity  of  the  body.  Now 
the  thorax  should  develop,  the  lungs  grow 
and  the  esophagus  lengthen,  while  the  dia- 
phragm, starting  from  its  periphery,  should 
close  in  toward  the  center,  separating  the 
abdomen  and  thorax  with  the  organs  which  belong  to  each.  But  if 
that  diaphragmatic  development  fails  to  take  place  properly,  or  is 


Fig.  200.  Lungs,  peri- 
cardium AND  THYMUS 
gland  in  case  of  dia- 
phragmatic hernia 
shown  in  Fig.  199,  one- 
quarter    actual    size. 


HERNIA  603 

delayed  until  the  organs  are  so  large  that  the  separation  cannot  take 
place,  the  consequence  is  a  congenital  diaphragmatic  hernia. 

In  the  ordinary  forms  of  diaphragmatic  hernia  the  abdominal 
viscera  pass  through  one  of  the  naturally  weak  points  in  the  dia- 
phragm, usually  near  the  ensiform  cartilage. 

The  traumatic  form  occurs  from  puncture,  incision  or  tearing 
of  the  diaphragm. 

Syjiiptoms  and  Diagnosis. — The  symptoms  may  be  very  ob- 
scure and  difficult  of  interpretation.  There  are  pain,  dyspnea,  and, 
upon  auscultation,  gurgling  of  intestinal  or  stomach  contents  in  the 
chest  cavity  and  perhaps  a  displaced  heart.  Strangulation  may 
occur  in  the  ordinary  and  traumatic  varieties. 

Treatment. — In  the  congenital  variety  nothing  can  usually  be 
done.  Most  cases  of  ordinary  diaphragmatic  hernia  are  not  diag- 
nosed unless  strangulated  and  operated.  If  a  congenital  dia- 
phragmatic hernia  is  strangulated,  and  operation  is  undertaken,  it 
may  be  found  that  the  hernial  mass  is  too  large  to  be  reduced  into 
the  abdomen,  having  been  long  resident  in  the  thorax.  In  this  case 
the  constriction  should  be  relieved  and  steps  taken  to  prevent  its 
recurrence,  and  no  further  attempt  made  to  reduce  or  to  close  the 
hernial  opening.  The  traumatic  varieties  should  be  operated  if  a 
diagnosis  can  be  made.  The  thorax  should  be  opened,  the  hernia 
reduced  and  the  opening  closed  by  suture.  If  there  is  evidence  of 
injury  also  to  abdominal  organs  the  abdomen  must  be  opened  and 
the  damage  repaired.  But  the  hernia  is  reduced  and  the  opening 
closed  best  from  the  thoracic  side. 

VENTRAL  HERNIA 

Ventral  hernia  usually  occurs  through  a  hiatus  in  the  linea 
alba.  This  has  been  referred  to  in  the  Section  on  The  Abdomen 
and  Its  Malformations.  It  should  be  treated  on  the  same  general 
principles  as  umbilical  hernia. 

UMBILICAL  HERNIA 

Exomphalos  has  already  been  described  as  a  malformation  of 
the  umbilicus.  That  form  of  hernia  usually  called  umbilical  occurs 
in  two  varieties.  In  one  the  protrusion  really  takes  place  through 
the  umbilical  aperture  into  the  cord,  or  rather,  the  stump  of  the 
cord,  being  covered  by  the  skin,  superficial  fascia,  and  peritoneum ; 
while  the  other  projects  in  the  linea  alba  immediately  above  the 
umbilicus. 

Diagnosis  is  easily  made  by  the  position  and  feel  of  the  tumor. 
It  is  soft  and  elastic,  and  usually  disappears  with  a  gurgle  when 
pressed  upon.     It  reappears  on  the  slightest  straining,  laughing  or 


6o4  SURGICAL  DISEASES    OF   CHILDREN 

crying.  In  some  cases  this  frequent  wedging  out  and  in  througli 
the  opening  seems  to  be  painful  and  make  the  child  fretful.  It  is 
always  unsightly. 

Prognosis  is  good.  It  is  very  seldom  that  an  umbilical  hernia 
in  a  child  becomes  strangulated,  or  that  it  persists  to  adult  life. 
Some  are  persistent  and  troublesome  and  would  not  close  without 
treatment  or  operation. 

Treatment. — Umbilical  hernia  is  often  treated  domestically, 
and  it  is  often  treated  by  the  physician  with  but  little  improve- 
ment over  the  methods  of  the  mother  or  the  mother's  neighborly 
advisers.  Sometimes  a  pad  of  muslin  or  cotton,  or  a  coin,  or  a 
piece  of  sheet  lead  is  bandaged  on ;  and  one  has  more  than  once 
seen  an  inguinal  hernia  produced  by  bandaging  an  umbilical  hernia 
too  tightly.  Sometimes  the  coin  or  a  disc  of  metal,  either  bare  or 
covered  with  lint,  or  a  cake  or  hemisphere  of  beeswax,  with  the 
convex  side  inward,  is  fastened  upon  the  abdomen  with  a  patch  of 
adhesive  plaster  and  maybe  a  cotton  or  flannel  binder  is  pinned  or 
sewn  over  all. 

Another  plan  is  to  draw  the  skin  in  a  fold  across  the  rupture 
and  fasten  it  thus  with  adhesive  straps,  changing  the  dressing 
every  few  days  or  a  week.  Also  one  can  buy  in  the  instrument 
stores  hard  rubber  pads  with  elastic  webbing  attached  to  encircle 
the  body.  These  pads  usually  have  upon  the  bearing  surface  a 
conical  or  hemispherical  projection  intended  to  press  the  protrud- 
ing viscus  within  the  hernial  opening.  If  the  projection  upon  the 
truss  is  maintained  constantly  within  the  opening  the  tendency  is 
to  keep  it  open.  Such  is  the  effect  of  the  hemisphere  of  beeswax, 
the  pad  with  the  conical  projection,  or  any  similar  object  when 
strapped  upon  the  rupture.  They  do  harm  rather  than  good.  How- 
ever, the  pads  when  applied  with  elastic  webbing  or  a  belt  never 
stay  in  place  at  all,  but  slip  about  in  any  direction  and  effect 
nothing. 

The  best  surface  to  prevent  the  rupture  from  projecting  and 
at  the  same  time  not  to  prevent  the  opening  from  closing  is  a  flat 
surface.  Some  slight  cases  in  infants  in  arms,  free  from  excessive 
coughing  or  straining,  do  perfectly  well  with  a  disc  of  thin  board 
two  and  one-half  or  two  and  three-quarters  inches  in  diameter  placed 
in  a  pocket  sewed  to  the  bellyband.  But  under  conditions  less 
favorable  the  pad  should  be  held  accurately  in  place  and  kept 
there  continuously  for  weeks  or  even  months,  until  the  opening 
closes.  This  fixation  of  the  pad  can  only  be  maintained  with  ad- 
hesive plaster.  But  this  is  done  with  considerable  inconvenience  on 
the  part  of  the  doctor  and  the  nurse,  and  sometimes  with  suffering 
on  the  part  of  the  patient.  The  skin  of  the  umbilicus  underneath  the 
pad  becomes  irritated  or  inflamed.    Every  little  while  one  sees  a  child 


HERNIA  60s 

with  miliaria,  dermatitis,  eczema,  or  even  with  ulceration,  devel- 
oped under  one  kind  or  another  of  umbilical  pad. 

The  same  objection  holds  against  the  plan  of  drawing  the 
skin  in  a  fold  across  the  rupture  and  holding-  it  thus  with  adhesive 
straps.     Fig.  201  illustrates  a  pad  or  plate  made  of  any  smooth, 


Fig.  201.  Author's  truss  for  umbilical  hernia.  At  the  top  of  the  illus- 
tration are  shown  both  sides  of  the  truss  pad  of  hard  rubber.  Secondly, 
the  pad  with  adhesive  strap  attached  ready  for  application.  Thirdly, 
the  truss  with  one  side  unbuttoned  and  pad  turned  back  as  for  cleansing 
or  powdering  the  umbilicus. 

impervious  material ;  gutta  percha  is  the  best,  with  little  buttons  or 
pegs  on  the  back  of  it  to  which  are  buttoned  the  ends  of  the  adhesive 
straps.  They  can  be  made  of  any  shape  and  of  different  sizes  and 
the  number  of  buttons  or  pegs  is  not  an  essential  point.  There 
should  be  at  least  two  buttons  and,  if  not  more  than  two,  they  should 
be  placed  vertically  with  reference  to  the  body.  The  square  shape 
with  rounded  corners,  and  about  two  and  one-quarter  inches  across, 
with  four  buttons,  I  find  convenient,  A  couple  of  inches  of  one 
end  of  each  adhesive  strap  is  folded  upon  itself  and  this  folded 
again  so  that  there  are  three  thicknesses  of  plaster  strengthening 
the  end.  Through  this  a  buttonhole  a  half  inch  from  the  end  is  cut 
with  a  penknife.  The  folded  end  prevents  the  plaster  from  adher- 
ing to  the  skin  near  the  pad.  The  straps  are  buttoned  on  to  the  pad 
and  adjusted  round  the  body.  When  the  abdominal  muscles  are 
weak,  flabby  or  over-stretched  the  straps  should  be  applied  just 
tightly  enough  to  support  them.  Fig,  202  shows  the  truss  applied. 
The  straps  can  be  unbuttoned  and  the  pad  removed  at  any 
time,  the  skin  cleansed  and  powdered,  and  the  pad  washed  and 
replaced  with  the  greatest  convenience  and  without  removing  the 
plaster  from  the  skin.     If  one  will  take  the  precaution  to  wash 


6o6 


SURGICAL   DISEASES    OF   CHILDREN 


thoroughly  and  antiseptically  all  portions  of  the  skin  that  are  to 
be  covered,  either  with  pad  or  plaster,  then  pass  the  face  of  the 
plaster  over  the  flame  of  an  alcohol  lamp  before  applying  it,  the 
strapping  can  be  left  on  for  weeks  together  and  the  mother  or  nurse 
can  do  the  rest.  In  a  few  weeks  or  a  few  months  the  hernial  open- 
ing is  closed. 

Operation  for  Umbilical  Hernia. — It  is  only  in  extremely  large 
or  persistent  umbilical  hernise  that  operation  is  necessary,  as  they 

are  nearly  always  curable  within  a  rea- 
sonable time  by  the  use  of  a  truss. 
Among  2000  operations  at  all  ages  for 
the  radical  cure  of  hernia  at  t*he  Hospi- 
tal for  Ruptured  and  Crippled,  New 
York,  from  1890  to  1907,  as  reported  by 
Bull  and  Coley,  only  thirteen  were  cases 
of  umbilical  hernia  in  patients  under 
fourteen  years  of  age.  When  the  opera- 
tion is  deemed  advisable  the  diet  should 
be  regulated,  the  bowels  well  emptied, 
and  tympanites  conquered,  all  the  anti- 
septic precautions  for  an  abdominal  sec- 
tion be  carried  out.  A  modification  of 
Ransohofif's  operation  is  adapted  to  these 
cases.  A  vertical  incision  skirts  the 
margin  of  the  umbilicus.  Expose  the 
aponeurotic  tissues  at  the  side  of  the 
neck  of  the  sac.  Open  the  sac  at  its  neck  and  reduce  any  hernial 
contents,  ligating  and  removing  any  adherent  omentum.  Introduce 
a  gauze  sponge  at  the  wound  so  as  to  hold  down  and  protect  ab- 
dominal contents  and  excise  sac  and  margins  of  its  opening,  and 
close  the  peritoneal  wound  with  running  catgut  sutures.  In  older 
children  it  is  well  to  expose  the  inner  margins  of  the  recti  muscles 
and  unite  them  with  kangaroo  tendon  sutures.  Or  the  posterior 
layer  of  the  rectus  sheath,  the  edges  of  the  muscles  themselves,  and 
the  anterior  layer  of  the  sheath  may  each  be  united  with  a  row  of 
sutures ;  and  finally  the  skin  is  closed.  Often  it  will  be  sufficient, 
after  closing  the  peritoneum,  to  strongly  unite  the  aponeurotic 
layers,  and  then  the  skin.  The  abdominal  walls  should  be  strongly 
supported  by  strapping  until  the  union  is  firm. 

INGUINAL  HERNIA 

The  inguinal  canal  in  the  child  is  not  a  very  long  canal.  The 
internal  and  external  rings  are  more  nearly  in  a  direct  line  from 
within  outward  than  in  the  adult.  It  is  only  with  development  and 
■widening  of  the  pelvis,  which  in  the  infant  is  small  and  rudimentary, 


Fig.  202.  Author's 
truss  for  umbilical 
HERNIA,   applied. 


HERNIA 


607 


that  the  internal  ring  assumes  a  position  so  much  farther  from  the 
median  Hne  than  the  external  ring  that  the  space  between  them  be- 
comes lengthened  into  an  oblique  canal.  In  consequence  of  this 
conformation  inguinal  hernia  in  a  child  is  almost  always  indirect 
or  oblique,  following  the  short  canal  easily  rather  than  pushing 
directly  through  internally  to  the  deep  epigastric  artery.  By  in- 
vaginating  the  scrotum  on  one's  finger  one  can  readily  demonstrate 
in  nearly  every  case  in  a  young  boy  the  shortness  and  straightness  of 
the  canal.  Inguinal  hernia  in  the  child  may  be  congenital,  funicular, 
infantile,  encysted,  or  acquired. 

Congenital  Hernia. — Any  of  the  varieties,  excepting  the  last, 


Fig.  203.  Congenital 
inguinal  hernia. 
Funicular  process 
open  into  peritoneal 
cavity.  Tunica  vag- 
inalis unseparated. 


Fig.  204.  Funicular 
HERNIA.  Funicular 
process  open.  Tu- 
nica vaginalis  sep- 
arated from  it. 


Fig.  205.  Infantile 
hernia.  Funicular 
process  and  tunica 
vaginalis  one  closed 
sac.  Hernia  behind 
it. 


may  be  congenital  in  the  sense  of  being  present  at  birth.  But  the 
variety  of  inguinal  hernia  called  congenital  descends  through  an 
open  funicular  process  which  has  failed  to  become  separated  from 
the  peritoneal  cavity  or  to  form  the  tunica  vaginalis.  The  loop  of 
intestines  descends  into  what  should  be  the  tunica  vaginalis.  Fig. 
203  illustrates  this  condition  diagrammatically.  In  congenital  her- 
nia in  girls  the  hernia  passes  into  the  canal  of  Nuck.     (Fig.  208.) 

Funicular  Hernia. — In  funicular  hernia  (Fig.  204)  the 
tunica  vaginalis  has  become  separated  from  the  funicular  process, 
but  the  latter  has  remained  open  and  contains  the  prolapsed  bowel. 

Infantile  Hernia. — In  infantile  hernia  the  funicular  process 
has  become  closed  at  the  abdominal  end,  but  is  still  one  with  the 
tunica  vaginalis.  A  hernia  with  a  separate  sac  of  peritoneum  comes 
out  through  the  rings  and  down  behind  the  funicular  process,  as 
shown  in  Fig.  205.  Thus  there  are  three  serous  layers  in  front  of 
the  bowel. 

Encysted  Hernia. — This  is  sometimes  described  as  a  second 
variety  of  infantile  hernia,  or  the  two  names  are  confounded.  In 
this  variety  the  same  condition  of  the  funicular  process  and  tunica 


6o8 


SURGICAL   DISEASES    OF    CHILDREN 


vaginalis  exists  as  in  infantile  hernia,  but  the  hernial  sac  in  its 
descent  invaginates  itself  into  the  process  below  it.  Thus  the  bowel 
has  two  serous  layers  in  front  of  it.     (Fig.  206.) 

Acquired  Hernia. — In  acquired  inguinal  hernia  (Fig.  207) 
the  funicular  process  has  become  obliterated,  leaving  the  tunica 
vaginalis  in  its  normal  situation  in  front  of  the  testicle.  The  hernial 
sac  is  entirely  independent  of  it,  and  may  be  incomplete  or  complete, 
that  is,  remain  in  the  canal  or  emerge  at  the  external  ring.  There  is 
a  growing  belief  that  in  many  so-called  acquired  hernise  there  is  a 
preformed  sac  that  is  congenital,  being  a  portion  of  the  processus 


Fig.  206.  Encysted 
HERNIA.  Funicular 
process  and  tunica 
vaginalis  one  closed 
sac.  Hernia  within 
it. 


Fig.  207.  Acquired 
inguinal  hernia. 
Possibly  the  sac  is 
after  all  a  re- 
opened funicular 
process. 


Fig.  208.  Hernia  in 
the  canal  op 
NucK.  This  corre- 
sponds to  congeni- 
tal hernia  of  the 
male. 


vaginalis  that  was  never  rightly  closed;  and  only  direct  hernise  are 
really  "  acquired." 

Diagnosis. — The  diagnosis  of  hernia  is  made  when  one  finds  in 
the  location  where  hernia  usually  occurs  a  rounded  or  oval  tumor 
which  gives  an  impulse  when  the  child  coughs,  laughs  heartily  or 
cries,  which  is  larger  when  the  child  stands  and  disappears  or  is 
easily  pressed  into  the  abdominal  cavity  when  he  lies  down.  The 
tumor  usually  contains  intestine,  is  smooth,  elastic,  may  be  tympa- 
nitic, and  is  apt  to  gurgle  when  compressed  or  on  reduction.  It  is 
usually,  but  not  always,  opaque  or  dark  colored  to  transmitted  light ; 
when  quite  empty  and  distended  with  gas  it  may  be  translucent. 
An  ovary  in  the  hernial  sac  is  small  and  firmer,  has  no  tympany 
nor  gurgling.  The  diagnosis  must  be  made  from  several  other 
swellings  likely  to  be  found  in  the  inguinal  and  scrotal  region.  One 
of  the  most  common  is  encysted  hydrocele  of  the  cord,  or  congenital 
hydrocele;  or  hydrocele  of  the  tunica  vaginalis  and  funicular  pro- 
cess, infantile  hydrocele  or  funicular  hydrocele ;  or  encysted  hydro- 
cele of  the  canal  of  Nuck;  or  cyst  of  the  hydatid  of  Morgagni,  which 
much  resembles  hydrocele.  Time  and  again  has  one  seen  children 
wearing  trusses  on  one  or  another  variety  of  hydrocele.    Hydrocele 


HERNIA 


6og 


has  a  different  feel  from  hernia.  If  reducible,  it  disappears  grad- 
ually and  not  in  a  mass,  and  it  reappears  in  the  same  manner,  has 
no  tympany  nor  gurgling.    It  is  translucent. 

An  undescended  or  a  wandering  testis  may  be  found  in  the  in- 
guinal canal  or  in  the  groin  or  the  perineal  region.  It  is  usually 
firm  and  irreducible,  and  its  normal  place  is  empty. 

Hernia  and  undescended  testicle  in  combination  deserves  spe- 


FiG.  209.  Double  scrotal 
HERNIA.  Congenital.  Note 
position  of  testicles.  The 
right  is  best  seen.  The  left 
is  at  the  same  height.  Com- 
pare with  the  funicular  her- 
nia shown  in  Fig.  211.  Boy 
2^    years    old. 


Fig.  210.  Same  case  as 
209,  after  operation.  One 
does  not  like  to  make  the 
radical  operation  for  hernia 
on  a  patient  under  4  years  of 
age.  Yet  under  urgent  cir- 
cumstances it  may  be  done, 
with    good    hope    of   success. 


cial  mention.  The  straying  loop  of  intestine  and  the  laggard  testis 
may  have  adhered  together,  with  the  peritoneum  between,  and  as 
the  testis  tries  to  descend  it  pulls  the  bowel  with  it,  and  when  one 
reduces  the  hernia,  the  testis  also  disappears  into  the  canal.  Hema- 
tocele would  show  ecchymosis  or  give  other  evidence  of  traumatism, 
if  not  a  history  of  it.  Varicocele  is  not  found  in  children.  Tumor 
of  the  testicle  may  occur,  but  usually  does  not  involve  the  cord,  is 
opaque  and  irreducible,  apt  to  be  hard,  perhaps  nodular. 

Dioi^nosis  of  the  Different  Varieties  of  Inguinal  Hernia. — A 
congenital,  funicular,  infantile  or  encysted  hernia  is  suspected  when 


6io 


SURGICAL   DISEASES    OF    CHILDREN 


a  hernia  appears  suddenly  in  a  young  subject,  promptly  attaining 
size  greater  than  would  occur  with  gradual  formation  of  a  sac.  It 
is  often  taught  that  the  varieties  are  distinguished  only  either  after 
death  or  upon  operation,  the  operator  dividing  one  serous  layer  if  it 
is   a   congenital   hernia    or   a    funicular   hernia,  whereas  he  divides 


Fig.  211.  Indirect  inguinal  her- 
nia OF  THE  funicular  VARIETY 
Observe  the  prominence  begins  at 
the  internal  ring;  and  the  lower 
end  of  the  scrotum  is  conical,  con- 
taining the  testicle  below  the  hernia 
which  is  globular.  Boy  5  years 
old. 


Fig.  212.  Same  case  as  Fig.  2ii. 
After  operation.  At  5  or  6  years 
is  a  better  age  for  operation  than 
earlier.  The  Bassini  method  is 
used,  sometimes  modified  by  not 
transplanting  the  cord.  In  chil- 
dren the  results  are  good  without 
transplantation. 


three  serous  layers  if  it  is  an  infantile  hernia  (or  as  some  indiscrimi- 
nately call  it  an  encysted  hernia),  or  two  layers  if  it  is  an  encysted 
hernia  as  herein  described.  But  as  a  matter  of  fact  one  can  often 
be  reasonably  certain  which  of  three  varieties  he  has  to  deal  with 
upon  examination.  Ordinary  acquired  hernia  appears  late  and  in- 
creases slowly,  and  if  it  descends  into  the  scrotum  it  remains  sepa- 
rate from  the  testicle.  The  congenital  variety  appears  early,  de- 
scends suddenly,  and  often  promptly  takes  a  position  lower  than  the 
testicle.  The  funicular  hernia  is  probably  far  more  common  than 
either  the  infantile  or  the  encysted  forms.    In  this,  the  hernia  appears 


HERNIA 


6ii 


early,  descends  rapidly,  but  usually  keeps  the  testicle  below  it.  These 
points  can  sometimes  be  detected  even  upon  inspection.  Fig.  209 
shows  a  boy  of  2  9-12  years  with  double  congenital  hernia.  The 
globular  shape  of  the  lower  end  of  the  hernial  tumor  is  well  seen 
at  the  bottom  of  the  tunica  vaginalis  upon  either  side.  The  outline 
of  the  right  testicle  is  plainly  shown  at  the  side  of  the  tumor.  The 
left  cannot  be  seen  in  the  picture,  but  it  was  at  the  same  level.  Fig. 
211  shows  a  case  of  funicular  hernia  of  the  right  side  in  a  boy  of 
five  years.  The  lower  end  of  the  scrotum  is  conical,  containing  the 
testicle  below  the  hernia,  which  is  more  globular.    One  mav  observe 


P'iG.  213.  Traumatic  orchitis  and  strangulated  inguinal  hernia.  On 
operation  part  of  the  cecum  with  the  appendix  found  in  the  sac.  Babe  two 
months  old.     Case  referred  by  Dr.  Robert  Tarr. 

also  that  the  prominence  above  begins  at  the  internal  ring,  showing 
that  the  hernia  is  oblique  or  indirect.  Figs.  210  and  212  show  the 
same  cases  after  operation. 

Prognosis. — The  prognosis  in  inguinal  hernia  in  infants  and 
children  is  good.  In  most  cases  removal  of  the  exciting  cause  with 
proper  trussing  will  effect  a  cure.  In  the  remainder,  operation  will 
in  all  probability  successfully  and  permanently  close  the  hernial 
opening. 

Treatment. — In  every  case  of  hernia  the  first  point  to  be  con- 
sidered in  the  treatment  is  removal  of  the  cause,  be  it  cough,  consti- 
pation, phimosis,  calculus,  frequent  crying,  malnutrition  with 
emaciation,  or  whatever  it  may  be.  In  some  instances  this,  with 
keeping  the  child  in  a  horizontal  position  for  a  time,  will  end  the 
trouble. 

In  other  cases  in  addition  to  this,  some  form  of  supporting  ap- 
paratus or  truss  must  be  used.      The  form  and  varieties  of  these 


6i2  SURGICAL   DISEASES    OF    CHILDREN 

appliances  are  numerous.  Some  of  them  are  good,  some  are  use- 
less, and  some  are  harmful.  Again,  a  good  appliance  may  be  badly 
applied  and  poorly  cared  for,  and  do  damage.  The  essential  points 
are  that  the  truss  shall  hold  the  hernia,  that  it  shall  do  so  without 
more  pressure  than  is  necessary  under  the  customary  strain,  that  it 
shall  maintain  its  position  no  matter  what  attitude  the  child  may 
assume  or  what  exercise  it  may  perform,  that  it  shall  not  irritate  the 
skin  and  that  it  shall  be  easily  kept  clean.  The  pad  should  be  of  a 
shape  and  size  to  cover  the  entire  inguinal  opening  without  boring 
into  either  ring,  and  should  be  hard  and  smooth  in  addition.  If  the 
truss  is  of  such  material  or  so  constructed  that  the  surgeon  can 
easily  alter  or  adjust  it  with  precision  to  the  patient,  and  is  not  too 
expensive,  there  is  little  more  to  be  desired.  A  well-fitting  inguinal 
truss  usually  does  not  require  any  perineal  band.  When  one  is  nec- 
essary I  have  long  been  in  the  habit  of  using  a  piece  of  rubber  tubing 
instead  of  a  leathern  strap.  This  is  round  and  does  not  cut  into  the 
skin ;  nor  does  it  stiffen  and  roughen  by  becoming  wet  or  soiled. 
Many  years  ago  I  attempted  to  introduce  the  skein  truss,  as  long 
and  extensively  used  for  infants  in  the  children's  clinics  in  England. 
(According  to  D'Arcy  Power  it  was  first  published  by  Mr.  William 
Coates  of  Wrington,  Somerset,  who  learnt  it  from  a  gudewife  in 
his  neighborhood.)  It  consists  of  a  skein  of  lamb's-wool  which  en- 
circles the  pelvis,  one  end  being  passed  through  the  other  and 
knotted  just  upon  the  inguinal  ring,  the  loose  end  being  carried  be- 
tween the  thighs  and  tied  behind  to  the  encircling  portion.  This  was 
changed  morning  and  evening  after  the  baths.  But  I  could  not  in- 
duce people  to  persist  in  its  use.  It  was  voted  too  much  trouble. 
There  was  a  disadvantage  in  the  daily  changing,  the  hernia  being 
likely,  in  unskillful  hands,  to  escape.  To  be  sure,  the  skein  truss  had 
only  its  cheapness  to  recommend  it.  For  a  spring  truss,  especially 
if  covered  with  celluloid  or  with  hard  rubber,  has  everything  in  its 
favor.  No  child  or  infant  is  too  small  to  be  fitted  with  a  truss.  It 
is  a  rare  hernia  that  cannot  be  held  with  a  truss.  Some  cases  can 
be  permanently  cured  in  a  few  months.  Most  cases  can  be  cured 
with  a  truss  within  two  years.  Once  the  truss  is  applied  the  hernia 
should  never  be  allowed  to  escape  during  the  whole  period  of  treat- 
ment. The  truss  is  to  be  worn  day  and  night  and  ever}^  moment. 
When  it  is  necessary  to  change  the  truss  or  wash  it  the  hernia  must 
be  carefully  held  in  by  the  fingers  of  the  mother  or  nurse.  The 
skin  beneath  the  truss  should  be  kept  scrupulously  clean  and  dry. 
The  mother  or  nurse  should  be  clearly  instructed  that  if  the  rupture 
comes  out  while  the  truss  is  on,  the  truss  is  to  be  immediately  taken 
off,  the  hernia  reduced  and  the  truss  reapplied ;  and  the  child  is  to 
be  brought  to  the  surgeon  and  the  occurrence  reported.  The  hernia 
may  be  considered  permanently  cured  when  the  pillars  arc  felt  to  be 


HERNIA  613 

of  normal  strength  and  properly  approximated;  and  there  Is  no  ten- 
dency for  the  rupture  to  come  down,  and  no  impulse  during  con- 
tinuous coughing  or  straining;  and  this  condition  has  been  main- 
tained for  several  weeks  after  leaving  off  the  truss.  As  a  rule,  cases 
which  cannot  be  held  with  a  truss  applied  by  skillful  hands,  and 
cases  in  which  trussing  has  been  properly  tried  for  a  period  of  two 
years  without  a  cure,  should,  if  the  child  has  reached  four  years  of 
age,  be  subjected  to  operation.  In  selected  cases  under  four  years 
of  age  which  could  be  trussed,  or  in  children  over  that  age  who  have 
not  been  trussed,  but  for  whom  it  is  impossible  to  get  home  care  or 
supervision,  the  surgeon  should  in  the  interest  of  the  patient  exercise 
his  discretion  upon  the  question  of  operation.  At  five  or  six  years 
is  a  better  time  to  operate  than  at  four  years,  if  the  patient  can  be 
safely  carried  along  till  that  time.  If  he  is  past  four  years  he  is  not 
so  likely  to  be  cured  by  a  truss,  but  he  can  be,  in  some  families, 
safely  carried  along  to  five  or  six  years  with  advantage,  and  then 
operated.  Cases  have  been  operated  upon  at  the  age  of  a  few  months 
or  even  a  few  weeks,  not  only  with  a  successful  result  at  the  time, 
but  with  a  cure  that  has  lasted  for  many  years  and  bids  fair  to  last  a 
lifetime.  In  many  cases  in  puny  infants  and  very  young  and  rickety 
children,  the  pillars  are  so  filmy,  so  badly  developed  or  stretched  out, 
that  it  is  better  to  use  a  truss  for  a  time,  as  there  is  very  little  tissue 
from  which  to  erect  a  barrier  and  the  condition  is  not  fit  for  an 
operation  of  election.  Many  such  cases,  if  they  can  be  carefully 
treated  by  truss,  will  in  time  be  cured,  whereas  if  subjected  to  opera- 
tion the  result  will  be  a  failure.  The  risk  from  strangulation  during 
the  truss  treatment  is  so  small  that  it  need  not  enter  into  the  calcu- 
lation. The  complication  of  hernia  with  undescended  testicle  argues 
in  favor  of  rather  than  against  operation. 

Choice  of  Operation  for  the  Cure  of  Inguinal  Hernia. — After 
an  immense  amount  of  study  and  experimentation  upon  methods  of 
operation  and  upon  every  step  and  point  in  the  technique,  the  ma- 
jority of  the  surgeons  of  the  world  to-day  prefer  the  Bassini  opera- 
tion or  some  slight  modification  of  it  in  almost  all  of  their  work  upon 
inguinal  hernia,  in  children  as  well  as  in  adults.  It  has  been  claimed 
by  some  that  almost  any  kind  of  an  operation  would  be  successful 
in  a  child ;  but  this  opinion  has  never  been  held  by  men  of  experience 
with  children,  nor  by  general  surgeons  who  operate  upon  very  many 
cases  of  hernia  at  all  ages.  It  is  distinctly  denied  by  Bull  and  Coley. 
who  give  their  percentage  of  relapses  prior  to  the  Bassini  method 
at  40  per  cent,  within  the  first  year,  whereas,  with  the  Bassini 
(sometimes  modified  by  not  transplanting  the  cord),  it  is  about  1.4 
per  cent.  It  has  also  been  shown  by  the  same  operators,  and  others, 
that  in  children,  at  least,  it  makes  very  little  difference  in  the  results 
whether  the  step  of  transplanting  the  cord  is  performed  or  not.     It 


6i4  SURGICAL   DISEASES    OF   CHILDREN. 

need  not  be  done  as  a  routine  step  excepting  in  direct  hernise 
(which  are  extremely  rare  in  children),  and  should  not  be  done 
in  cases  of  undescended  testicle,  as  the  cord  is  longer  without 
transplanting. 

Preparation  for  and  Technique  of  the  Operation. — It  is  essen- 
tial that  the  child's  digestive  organs  be  in  good  order  and  that  the 
intestines  be  nearly  empty  and  free  from  gas.  The  diet  should  be 
carefully  regulated  for  some  days  previous  to  the  operation  and  for 
twenty-four  or  thirty-six  hours  previously  should  consist  only  of 
easily  digested  or  predigested  liquids  which  will  leave  little  residue 
and  not  be  likely  to  ferment.  During  this  preparatory  dieting  or  at 
least  for  a  couple  of  days,  the  child  should  be  kept  in  bed  to  accustom 
him  to  being  quiet.  Each  day  he  should  have  a  bath  with  warm 
water  and  soap.  Twenty-four  hours  before  the  time  set  for  the  op- 
eration, the  abdomen,  pubes,  loins  and  thighs  should  be  scrubbed 
with  warm  water  and  green  soap,  using  a  sponge  of  gauze  or  flannel 
for  rubbing,  followed  after  thorough  rinsing  with  alcohol  and  a 
solution  of  mercuric  bichloride  i  to  2000.  A  compress  wrung  from 
bichloride  solution,  i  to  5000,  should  be  applied,  covered  with  dry 
cotton  and  a  bandage.  When  placed  upon  the  table  the  parts  are 
again  cleansed  in  the  same  manner.  The  extremities  are  covered 
with  dry  cotton  bandaged  on,  or  with  woolen  drawers  with  feet,  and 
the  patient  surrounded  with  hot-water  bottles  during  the  opera- 
tion. The  most  scrupulous  preparation  of  instruments  and  hands 
is  essential,  and  rubber  gloves  should  be  worn  by  operator  and 
assistants. 

The  incision  is  made  parallel  to  Poupart's  ligament,  upon  the 
inguinal  canal.  This  exposes  the  aponeurosis  of  the  external  oblique. 
A  grooved  director  is  introduced  into  the  canal,  which  is  slit  up  by 
a  series  of  two  or  three  little  snips,  the  director  being  readjusted 
between  each  snip.  The  wound  should  be  kept  very  dry  by  the  use 
of  hemostats,  lest  the  tissues,  becoming  blood-stained,  be  hard  to 
distinguish.  The  sac  is  recognized  by  its  white  color  and  its  struc- 
ture. The  sac  is  lifted  up  and  dissected  from  the  tissues  beneath. 
This  is  more  readily  done  by  beginning  on  the  inner  side  and  circling 
round  it  before  working  upward  or  downward.  Unnecessary  injury 
to  the  cremasteric  fibers  should  be  avoided.  If  the  lower  end  of  the 
sac  does  not  go  down  to  the  testicle,  that  is,  if  it  is  an  acquired,  a 
funicular,  infantile,  or  encysted  hernia,  the  sac  may  be  dissected 
out  completely  at  its  lower  end.  In  congenital  hernia  enough  of  the 
sac  should  be  left  at  its  lower  end  to  make  a  tunica  vaginalis.  In 
the  other  forms  of  hernia  it  is  not  essential  that  the  entire  lower  end 
of  the  sac  should  be  removed,  but  in  all  it  is  essential  that  the  floor 
of  the  sac,  that  is,  the  posterior  part,  should  be  dissected  up  and  sep- 
arated from  the  cord.    The  cord  should  be  handled  very  gently  and 


HERNIA  6t5 

not  compressed.  The  complete  neck  of  the  sac  should  be  lifted  up 
and  opened  and  the  margins  of  the  opening  caught  with  hemostats 
and  spread  so  that  the  surgeon  can  see  that  the  sac  is  empty.  The 
sac  is  drawn  out,  transfixed  and  tied  with  medium  sized  chromicized 
catgut  as  high  above  its  neck  as  possible,  cut  off,  and  the  stump 
allowed  to  disappear  into  the  wound.  If  the  cord  is  to  be  trans- 
planted it  is  held  up  out  of  the  way  by  a  loop  of  sterile  gauze  or  tape 
or  a  blunt  hook,  while  the  sutures  are  being  passed  and  tied.  For 
this  purpose  a  needle  armed  with  twenty-  or  thirty-day  chromicized 
kangaroo  tendon  is  passed  through  the  edges  of  the  transversalis 
fascia,  the  transversalis  and  the  internal  oblique  and  the  rectus  on 
the  internal  side  of  the  canal,  and  the  same  excepting  the  rectus  in 
the  external  pillar,  and  they  are  brought  together  and  tied  under- 
neath the  cord.  Either  mattress  or  ordinary  sutures  will  answer. 
My  own  preference  is  for  the  mattress.  From  two  to  four  pairs  are 
passed  below  the  cord,  the  upper  one  just  touching  it,  attaching  the 
internal  pillar  to  Poupart's  ligament.  One  suture  is  placed  above 
the  cord,  care  being  taken  not  to  compress  either  the  vas  deferens 
or  its  vessels.  At  the  lower  end  of  the  canal,  after  passing  the  needle 
through  the  internal  oblique,  Coley  passes  it  through  the  fascia  of 
the  muscle  just  where  it  reflects  back,  and  this  drawn  across  to  Pou- 
part's ligament,  strengthens  the  closure  at  the  lower  angle  just  above 
the  pelvic  brim,  where  recurrence  is  apt  to  take  place.  In  passing 
the  needle  one  should  be  cautious  not  to  wound  the  viscera  or  the 
iliac  vessels.  Pointing  the  needle  obliquely  as  it  passes  under  the 
edge  of  the  wound  and  guarding  it  with  the  finger-tip  lessens  this 
danger.  This  suture  line  forms  the  posterior  wall  of  the  new  canal. 
Upon  this  the  cord  is  laid,  and  the  divided  aponeurosis  of  the  exter- 
nal oblique  is  drawn  over  it  and  held  with  a  continuous  suture  of 
catgut,  thus  making  the  anterior  wall  of  the  new  canal.  As  before 
stated,  it  is  not  always  necessary  to  transplant  the  cord.  If  this  is 
not  to  be  done,  after  tying  and  removing  the  sac  the  cord  is  replaced 
in  its  old  position  and  the  canal  closed.  The  wound  should  be  dry, 
and  the  skin  incision  is  now  closed  without  drainage,  with  silkworm 
gut  or  catgut  sutures.  In  former  years  silk  was  used  for  tying  the 
sac,  and  silver  wire  or  silk  for  closing  the  canal.  I  have  formerly 
used  both,  especially  silk,  with  satisfaction.  But  nowadays  hardly 
anyone  uses  non-absorbable  material  for  buried  sutures.  Chromi- 
cized kangaroo  tendon  for  the  canal,  chromicized  catgut  for  the  sac 
and  ordinary  sterilized  catgut  for  the  vessels  and  muscles  are  prob- 
ably the  choice  of  the  majority  of  surgeons.  The  wound  is  dressed 
with  gauze,  adhesive  strapped  on,  cotton,  a  spica  bandage,  and  a 
plaster  of  Paris  bandage  going  from  the  knee  to  the  thorax.  In 
some  clinics  the  plaster  of  Paris  bandage  is  carried  no  higher  than 
the  navel,  on  the  theory  that  more  room  is  given  for  possible  disten- 


6i6  SURGICAL   DISEASES    OF   CHILDREN 

sion  of  intestines  away  from  the  wound  and  less  at  the  wound  by 
so  doing.  Some  use  no  plaster  of  Paris  at  all,  in  order  that  wetting 
the  dressing  may  be  more  easily  detected.  But  I  think  it  safer  in 
most  cases  in  children  to  use  plaster,  and  if  the  plaster  is  not  carried 
up  on  the  thorax,  other  means  should  be  taken  to  prevent  the  child 
from  raising  up  or  twisting  about  during  the  first  few  days,  as 
strain  may  be  put  upon  the  wound  by  so  doing.  In  young  children 
who  wet  and  soil  themselves  it  is  safer  to  seal  the  wound  with  iodo- 
form gauze  and  collodion,  and  outside  of  the  dry  sterile  gauze  to 
place  rubber  tissue  so  disposed  as  to  keep  the  wound  clean  and  dry. 
With  bedwetters  all  precautions  should  be  taken  to  prevent  soiling 
of  dressings,  as  the  results  of  the  most  skillfully  performed  operation 
may  easily  be  ruined.  (49) 

At  the  end  of  a  week  ordinarily  the  plaster  is  removed  and  the 
first  dressing  made,  the  skin  sutures  being  removed,  and  usually  the 
patient  can  be  allowed  to  sit  up  in  a  reclining  chair. 

FEMORAL  HERNIA 

In  children  the  pelvis  is  comparatively  small  and  narrow,  and 
the  pelvis  of  the  girl  is  much  like  that  of  the  boy.  The  crural  ring 
is  small.  Ligament  and  pelvis  are  close  together,  and  the  iliacus  and 
psoas  muscles  and  the  femoral  vessels  fill  the  space  so  completely 
there  is  small  chance  for  a  hernia  to  wedge  through.  Congenital 
femoral  hernia  never  occurs.  It  is  always  of  the  acquired  form 
and  is  rare  under  puberty.  When  it  does  occur  it  is  like  that  of  the 
adult,  an  elastic  swelling  in  the  groin  appearing  first  over  the  saphe- 
nous opening,  but  curving  up  over  the  groin.  Under  pressure  it 
gurgles  and  disappears  like  other  hernise.  But  on  account  of  its 
rarity  in  children,  and  the  frequency  of  spinal  or  sacral  caries  and 
resulting  abscess  appearing  in  this  region,  the  latter  should  be  care- 
fully excluded.  Enlarged  glands  bear  a  resemblance,  but  they  are 
often  multiple,  have  no  impulse  on  straining  and  cannot  be  reduced, 
and  there  is  often  an  obvious  cause.  Varix  of  the  saphena  should 
be  excluded.  Femoral  hernia  is  extremely  liable  to  strangulation. 
It  can  usually  be  retained  by  a  truss,  but  there  is  no  hope  of  a  cure 
by  trussing.  Therefore  it  is  useless  to  wait  if  a  patient  is  fit  for 
operation.  Bassini's  operation  is  probably  the  best.  The  incision  is 
made  over  the  center  of  the  tumor,  parallel  to  Poupart's  ligament. 
The  sac  is  separated  by  blunt  dissection,  then  transfixed  and  ligated 
as  high  up  as  possible.  The  excess  is  removed ;  or  at  this  point  a 
step  from  McEwen's  operation  may  be  introduced  if  desired;  that  is, 
the  sac  may  be  used  to  form  a  pad  drawn  up  into  the  opening  before 
closing  the  canal.  The  canal  is  closed  by  two  lines  of  interrupted 
sutures  of  kangaroo  tendon  or  silk.  The  first  line  unites  the  pecti- 
neal fascia  and  Poupart's  ligament ;  and  the  second  line  connects  the 


HERNIA 


617 


cribiform  fascia  and  Poupart's  ligament  and  the  fascia  above  the 
saphenous  opening.  The  iirst  sutures  close  the  opening  from  the 
abdomen  into  the  canal.  The  second  sutures  close  the  canal  itself. 
The  skin  and  superficial  fascia  are  then  sutured  without  drainage. 

LUMBAR  HERNIA 

Hernia  occasionally  occurs  just  above  the  iliac  crest  in  Petit's 
triangle.  It  may  be  congenital  or  traumatic,  or  result  from  weak- 
ening of  the  wall  by  abscess.  It  presents  the  usual  signs  of  hernia, 
and  should  be  treated  like  a  ventral  or  umbilical  hernia  with  a  pad 
held  in  place  by  adhesive  straps,  or  if  there  is  no  tendency  to  close 
by  this  means,  a  radical  operation  should  be  done.  This  was  first 
resorted  to  by  Edmund  Owen,  who  dissected  down  to  what  ap- 
peared to  be  the  transversalis  fascia,  thrust  the  sac  and  its  con- 
tents into  the  abdomen,  and  united  the  margins  of  the  external 
oblique  and  lattisimus  dorsi  with  sutures,  effecting  a  complete  cure. 
Such  hernige,  like  ventral  herniae,  seldom  present  a  distinct  neck. 
If  they  do  it  should  be  ligated. 

VAGINAL  HERNIA 

Vaginal  hernia  is  mentioned  as  a  rare  but  possible  condition 
even  in  infancy  or  childhood.  T.  Holmes  records  a  case  in  a  girl 
of  three  years  in  whom  the  tumor  protuded  behind  the  labia  minora, 
between  the  urethra  and  vagina,  being  evidently  an  extension  of 
the  vesico-vaginal  pouch  of  the  peritoneum.  It  contained  intestine, 
which  was  easily  reduced,  leaving  a  distinct  hiatus  or  ring  where  it 
had  protruded.  As  the  tumor  was  increasing  in  size  he  reduced  the 
hernia,  dissected  flaps  ofif  either  side  of  the  vagina  and  united 
them  around  the  ring  by  numerous  sutures.  Cicatrization  by  granu- 
lation followed  and  the  contraction  closed  the  ring-. 

TRAUMATIC,  POST-OPERATIVE,  RELAPSED  HERNIiE 

These  are  not  so  frequently  met  in  children  as  in  adults,  yet  they 
occur  occasionally,  from  accidental  injury  or  following  abdominal 
sections  for  appendicitis,  for  drainage  of  peritonitis,  for  tumors, 
failure  of  radical  operation  for  hernia,  et  cetera.  These  herniae 
may  often  be  retained  by  a  pad  and  belt  or  some  form  of  truss,  but 
they  show  no  tendency  to  improve  under  treatment  by  trussing. 
On  the  contrary  the  trouble  increases  by  stretching  of  the  scar  tis- 
sue, and  they  should  be  treated  on  the  same  principle  as  laid  down 
for  hernia  in  the  linea  alba  or  intractable  umbilical  hernia.  The 
scar  tissue  should  be  removed  and  the  aponeurotic  and  muscular 
layers  united  in  anatomical  order  by  sutures  of  catgut  and  kangaroo 
tendon.  In  operating  on  relapsed  hernia  it  is  best  to  start  the  dis- 
section for  the  canal  a  little  higher  up  to  avoid  the  scar  tissue,  and 
^fter  distinguishing  the  structures  to  work  downward.  _ 


CHAPTER  XXIII 
THE  RECTUM  AND  ANUS 

AXATOMY — EXAMIXATIOX    AXD    PATHOLOGY COX^GEXITAL    SmALL- 

XESS    OF    THE    AxUS — HYPERTROPHY    OF    THE    SPHINCTER    AnI 

— Malformations  of  the  Rectum  an'd  Imperforate  Anus 
— Prolapsus  of  the  Rectum — Nevus  of  the  Rectum — 
Polypus  of  the  Rectum — Bilharzia  Adenomata  of  the 
Rectum — Proctitis — Syphilis  of  the  Rectum  and  Anus — 
Vegetations  or  Warts  about  the  Anus — Fistula  in  Ano 
— Fissure  of  the  Anus — ^Hemorrhoids — Ischio-Rectal 
Abscess  —  Marginal  Abscess  —  Foreign  Bodies  and  Im- 
pactions— Ixefficiex^cy  of  the  Sphixcter  Ani. 

ANATOMY 

The  rectum  in  the  infant  and  young  child  may  be  described  as 
in  the  aduh,  as  following  the  anterior  outline  of  the  sacrum  and 
coccyx  and  being  in  contact  with  them  in  the  first  and  second  por- 
tions, then  turning  backward  in  its  downward  course  in  the  third 
portion.  But  the  sacrum  and  especially  the  coccyx  are  but  slightly 
curved  in  the  young.  They  are  almost  straight ;  and  the  curv^es  of 
the  rectum,  both  the  antero-posterior  and  the  lateral  curves,  are  only 
rudimentary.  The  rectum  is  almost  a  straight  tube,  placed  more 
vertically  in  the  long  axis  of  the  body  than  in  the  adult.  The  lowest 
curve  downward  and  backward  to  the  anus  does  exist  to  a  degree, 
and  should  not  be  forgotten  when  introducing  a  thermometer  or 
instruments  into  the  rectum.  In  the  infant  and  young  child  the  glu- 
teal muscles  are  not  much  developed,  so  that  the  anus  does  not  lie 
in  such  a  deep  fold  between  the  nates,  and  it  seems  rather  behind 
than  beneath  the  body,  by  comparison  with  the  adult.  The  rectum 
is  relatively  larger  than  in  the  adult.  Its  thick  mucous  membrane 
has  a  very  loose  attachment  to  the  muscular  coats  beneath.  The 
peritoneum  covers  the  front  of  the  rectum  to  about  the  level  of  the 
fourth  sacral  vertebra.  This  point  corresponds  to  about  the  middle 
of  the  symphysis  pubis.  There  is  a  meso-rectum  for  the  upper  por- 
tion of  the  rectum.  This  descends  as  low  as  the  third  sacral  ver- 
tebra. In  the  infant  as  in  the  adult  there  is  no  anatomical  line  of 
division  between  the  rectum,  and  the  sigmoid  flexure  at  the  level  of 
the  sacral  promontory. 

EXAMINATION  AND  PATHOLOGY 

The  disorders  of  the  rectum  and  anus  in  infants  and  children 
constitute  a  field  rather  neglected  in  practice.     Careful  examination 

6i8 


THE  RECTUM  AND  ANUS  619 

should  be  more  frequently  and  promptly  resorted  to  when  symptoms 
point  toward  this  region.  It  is  astonishing  to  find  that  even  in  the 
hands  of  average  practitioners  serious  malformations  and  diseases 
that  are  perfectly  obvious  upon  examination,  often  escape  detec- 
tion for  days,  weeks,  months  or  years,  for  want  of  proper  investi- 
gation. Doubtless  the  great  frequency  of  digestive  and  intestinal 
disorders  often  leads  to  hasty  diagnosis  of  functional  trouble  higher 
up  in  the  tract.  It  is  true  that  in  infants  and  children  the  small  size 
of  the  parts,  and  in  children  fear  and  lack  of  control,  render  ex- 
amination more  difficult  than  in  adults,  but  these  obstacles  are  to  be 
overcome  in  many  departments  of  our  work. 

In  even  the  new-born  baby  one's  fourth  finger,  well  oiled  and  hav- 
ing the  nail  trimmed  short  and  smoothly  can  be  readily  passed  for 
exploration.  In  most  infants  and  all  children  normally  formed,  a 
slender  index  finger,  lubricated,  passes  readily  and  safely  without 
overdilating  the  sphincter.  For  inspection  the  ordinary  types  of 
rectal  specula  of  small  size  can  be  used  in  older  children,  and  in 
infants,  urethral  specula.  Not  only  inspection  of  the  lower  rectum, 
and  digital  exploration,  but  complete  proctoscopy  and  sigmoidoscopy 
are  practicable  even  in  cases  of  acute  inflammation  and  in  children 
seriously  ill.^ 

But  most  of  the  diseases  of  this  region  are  found  within  an 
inch  and  a  half  of  the  anus.  Imperforation  is  most  frequently 
superficial.  Congenital  smallness  of  the  anus,  hypertrophy  of  the 
sphincter,  paralysis  and  over  relaxation  of  the  sphincter,  fissure, 
abscess,  fistula,  haemorrhoids,  nevus,  syphilis,  prolapsus  of  the 
rectum,  are  easily  within  reach.  Proctitis,  rectal  impaction,  for- 
eign bodies,  polypi  and  other  tumors,  ulcers,  strictures,  worms,  may 
be  encountered  low  in  the  rectum  or  higher.  Moreover,  by  this 
route  of  examination  other  ailments  than  ano-rectal  may  often  be 
detected  or  better  defined.  Such  are  deformities  of  the  pelvis,  sig- 
moid disease,  intussusception,  caries  of  pelvic  bones,  disease  of  hip 
joint  or  sacro-iliac  joint,  tubercular  glands,  vesical  tumor  or  cal- 
culus, malformations  and  diseases  of  the  vagina,  uterus,  ovaries, 
and  tubes,  intra-pelvic  testicles,  sacral  and  cocygeal  tumors.  So 
that  the  surgeon  should  familiarize  himself  with  methods  of  ex- 
amination per  rectum  and  their  findings  palpable  and  visible. 

CONGENITAL  SMALLNESS  OF  THE  ANUS 

In  this  the  structure  of  the  anus  is  complete  but  of  size  smaller 
than  normal.  This  produces  difficult  defecation  and  leads  to  dis- 
tressing secondary  symptoms  of  constipation  and  its  results.  Al- 
most always  the  remedy  is  found  in  gradual  dilatation;  but  if  this 

iBowditch:  Arch.  Ped.,  Jan.,  191 1. 


620  SURGICAL  DISEASES  OF  CHILDREN 

fails,    section    posteriorly   in   the  median   line   is   resorted   to   with 
success. 

HYPERTROPHY  OF  THE  SPHINCTER  ANI 
It  is  not  always  clear  whether  this  condition  is  congenital  or 
acquired.  Nor  is  it  always  easy  to  distinguish  whether  there  is 
actual  hypertrophy  of  the  sphincter  muscle,  or  only  hyper-activity, 
brought  about  by  morbidly  excitable  reflexes  or  local  irritation  or 
both.  But  it  sometimes  occurs  where  no  local  or  other  source  of 
reflex  irritation  can  be  found.  The  sphincter  appears  too  strong 
and  too  actively  contractile  for  the  expulsive  powers.  Treatment 
is  by  dilatation,  divulsion,  or  division  of  the  sphincter  muscle, 

MALFORMATIONS  OF  RECTUM  AND  IMPERFORATE  ANUS 

These  constitute  a  class  of  cases  most  interesting,  not  only  to 
the  pathologist  but  to  the  practical  surgeon.  Without  an  under- 
standing of  embryology  they  would  be  incomprehensible ;  and  with- 
out intelligent,  prompt  and  courageous  surgery  they  would  be  all 
miserably  hopeless.  On  the  other  hand,  their  etiology  is  beautifully 
explained  in  the  mutations  of  the  embryo;  and  nature's  errors  of 
this  kind  often  afford  a  field  for  brilliant  and  beneficent  surgical 
achievement.  A  brief  review  of  the  development  of  the  rectum  and 
anus  will  explain  the  production  of  some  of  these  deformities.  The 
intestinal  and  urinary  canals  are  at  first  all  in  one,  which  consists 
only  of  an  open  gutter  formed  from  the  epiblast  in  front  of  the 
spinal  column.  This  gutter,  later,  becomes  enclosed  as  a  tube  or 
sac,  and  its  lower  portion,  when  partitioned  off  from  the  intestine 
or  mesenteron,  becomes  the  bladder.  As  the  cloacal  opening  be- 
tween bladder  and  mesenteron  closes,  a  special  opening,  the  urethra, 
connects  the  bladder  with  the  surface.  While  the  lower  end  of  the 
mesenteron  as  a  blind  pouch  extends  downward  in  the  situation  of 
the  rectum,  a  depression,  called  the  proctodeum,  from  the  epiblast 
at  the  base  of  the  embryo  opens  inward  to  meet  the  mesenteron, 
thus  forming  the  anus.  If  the  perineal  septum  fails  to  separate  the 
mesenteron  from  the  urinary  tract,  one  of  those  deformities  is  pro- 
duced in  which  there  is  a  communication  between  the  rectum  and 
the  bladder  or  urethra.  If  the  mesenteron  fails  to  descend  or  the 
proctodeum  to  dimple  in  far  enough,  the  two  do  not  meet,  and  there 
is  produced  imperforate  anus,  one  of  the  forms  of  malformation  of 
the  rectum  about  to  be  described  more  in  detail.  It  is  stated  by 
some  writers  that  ano-rectal  imperforation  is  apt  to  be  accompanied 
by  other  deformity,  especially  by  contracted  pelvis,  extroversion  of 
the  bladder,  spina  bifida  or  naso-pharyngeal  obstruction ;  but  in  none 
of  the  cases  that  I  have  seen  was  such  malformation  present.     (59.) 

Ano-rectal  imperforation  occurs  perhaps  once  in  five  thousand 
or  six  thousand  births. 


THE    RECTUM    AND    ANUS  621 

Classification. — The  classification  of  the  congenital  malfor- 
mations of  the  rectum  and  anus  as  adopted  and  modified  by  Boden- 
hamer  in  i860  still  is,  as  that  author  remarked,  "  if  not  perfect, 
.  .  .  sufficiently  plain,  comprehensive  and  correct  for  all  prac- 
tical purposes."     Slightly  modified  in  wording  it  is  as  follows : 

I.  Preternatural  narrowing  of  the  anus  or  rectum  without  com- 
plete occlusion. 

II.  Complete  occlusion  of  the  anus  by  a  simple,  membranous 
diaphragm  or  by  integument. 

III.  The  anus  is  absent,  the  rectum  ends  in  a  cul-de-sac  at  a 
greater  or  less  distance  above  its  natural  outlet,  without  any  com- 
munication whatever,  externally  or  internally. 

IV.  The  anus  is  normal  externally,  but  ends  in  a  cul-de-sac ; 
and  the  rectum  ends  in  a  blind  pouch  at  a  greater  or  less  distance 
above,  the  two  being  separated  by  a  septum. 

V.  The  anus  is  absent.  The  rectum  is  prolonged  in  the  form 
of  a  fistulous  sinus  and  terminates  by  an  abnormal  anus  at  the  glans 
penis,  the  labia  pudenda,  or  at  any  point  about  the  perineum  or 
sacrum. 

VI.  The  anus  is  absent.  The  rectum  terminates  in  the  bladder, 
urethra,  or  vagina ;  or  into  a  cloaca  in  the  perineum  with  the  urethra 
and  vagina. 

VII.  The  anus  and  rectum  are  normal,  but  the  ureters,  the 
vagina  or  the  uterus  open  into  the  rectal  cavity. 

VIII.  The  rectum  is  entirely  absent. 

IX.  The  rectum  and  colon  are  both  absent,  and  there  is  usually 
an  abnormal  sinus  situated  in  some  extraordinary  part  of  the  body. 

Of  each  of  these  species  there  are  several  varieties.  Some  of 
these  have  been  illustrated  here  by  original  diagrammatic  drawings 
after  the  descriptions  of  standard  authors  but  based  upon  infantile 
anatomy.  (See  Figs.  214  to  222.)  All  these  malformations  present 
some  symptoms  in  common ;  and  much  that  could  be  said  upon  diag- 
nosis and  treatment  applies  to  all  of  them;  yet  it  is  obvious  that  each 
species  has  peculiarities  which  will  require  its  separate  considera- 
tion, either  on  account  of  symptoms,  diagnosis  or  treatment. 

Species  I. — In  this  species  the  narrowing  may  be  so  slight  as  to 
occasion  very  little  inconvenience  further  than  some  straining  when 
the  feces  are  too  firm  in  consistency ;  or  so  extreme  as  to  scarcely 
admit  a  catheter  or  a  probe,  and  to  cause  severe  straining  with  the 
escape  of  very  little  feces  which  accumulate  and  distend  the  abdo- 
men, occasioning  pain.     (See  Fig.  214.) 

Diagnosis. — The  diagnosis  is  readily  made  by  examination  of 
the  rectum.  The  only  difficulty  likely  to  arise  is  in  ascertaining  the 
length  of  the  narrow  portion  when  it  extends  high  up. 

Prognosis. — The  prognosis  is  usually  good. 


622 


SURGICAL   DISEASES    OF   CHILDREN 


Treatment. — The  treatment  of  this  variety  is  by  gradual  dila- 
tation. If  the  opening  is  too  small  or  the  narrowed  portion  too  long 
for  a  well-oiled  finger  to  pass,  the  dilatation  may  be  done  with  grad- 


Fig.  214. 


Fig.  217. 


Fig.  220. 


Fig.  218. 


Fig.  219. 


Fig.  222. 


Figs.  214,  215,  216,  217,  218,  219,  220,  221,  and  222,  illustrating  malforma- 
tions OF  THE  RECTUM   AND   IMPERFORATE  ANUS. 

uated  bougies.  I  have  sometimes  found  small  wax,  tallow  or  stearine 
candles  answer  the  purpose  very  well.  Sometimes  the  little  finger 
and  later  the  index  finger  of  the  nurse  or  mother,  well  smeared  with 
vaseline  and  passed  daily,  will  accomplish  all  that  is  necessary.    Care 


THE    RECTUM    AND    ANUS 


623 


should  be  taken  not  to  irritate  or  excoriate  the  mucous  Hning;  nor 
to  overstretch  the  tissues  by  dilating  too  rapidly.  Obstructing-  bands 
or  folds  may  need  dividing.  The  process  of  dilation  may  have  to 
be  kept  up  very  patiently  for  weeks  and  months  and  even  years. 
Attention  should  be  directed  to  the  diet  and  digestion'  in  order  that 
the  stools  may  be  of  the  right  consistency. 

Species  II. — In  cases  of  occlusion  of  the  anus  by  a  simple  mem- 


FiG.  223.  Imperforate  anus  with  a  tapering  tail-like  ridge  extending  for- 
ward from  the  region  of  the  coccyx,  dividing  the  cup-Hke  cavity  o'f  the 
proctodeum  into  lateral  halves. 

branous  diaphragm  or  by  integument  (Fig.  215),  the  site  where  it 
should  be  may  be  quite  smooth  like  ordinary  skin,  or  it  may  have 
the  papillary  arrangement  of  the  raphe  of  the  scrotum  or  perineum, 
without  either  elevation  or  depression  from  the  surface,  or  there 
may  be  a  dimple  or  a  slight  groove  at  the  anal  site.  More  rarely 
there  is  a  depression  or  cupping  at  the  situation  of  the  anus — with 
a  bridge  of  skin  extending  antero-posteriorly  across  it.  Again  there 
occurs,  rarely,  the  condition  shown  in  Fig.  223,  in  which  a  tapering 
process  like  a  tail  extends  forward  from  the  coccygeal  region  across 
the  anal  site,  dividing  the  cup-like  cavity  of  the  proctodeum  into 


624  SURGICAL   DISEASES    OF   CHILDREN 

lateral  halves.  This  seems  to  contradict  the  usually  accepted  view 
that  the  ectodermal  layer  simply  dimples  in  until  it  meets  the  termi- 
nus of  the  enteron.  It  rather  confirms  the  description  of  Tourneux, 
that  there  is  a  definite  anal  membrane  or  specialized  cellular  mass 
thicker  in  the  middle  line  than  at  the  sides,  forming  the  anterior 
wall  of  an  internal  cloaca  or  rectal  ampulla ;  and  that  this  cellular 
body  is  absorbed  away,  the  greatest  absorption  taking  place  at  each 
side  of  the  central  line,  where  the  thicker  portion  remains  the  last 
to  be  absorbed,  and  in  such  malformations  as  this  fails  to  be  ab- 
sorbed. 

This  description  of  external  appearances  applies  not  only 
to  species  II.,  but  to  all  the  nine  species  of  Bodenhamer's  classifica- 
tion in  which  the  anus  is  absent.  The  occluding  septum  may  be 
quite  thin  and  membranous  or  resemble  ordinary  skin  or  be  consid- 
erably thicker  or  firmer.  The  sphincters  are  often  normally  devel- 
oped. 

Symptoms  and  Diagnosis. — ^Restlessness  and  distress  with  re- 
fusal to  take  the  breast  are  symptoms  usually  present,  and  should 
attract  attention,  but  often  do  not.  Distension  of  the  abdomen  and 
straining  without  defecation  supervene  and  are  noticed  sooner  or 
later.  Examination  reveals  the  imperforation.  Often  there  is  bulg- 
ing of  the  septum  during  the  straining. 

Treatment. — The  treatment  of  this  species  of  malformation  is 
quite  simple  and  satisfactory.  A  crucial  incision  of  the  membrane 
or  skin  is  first  made  and  the  small  flaps  trimmed  off  if  they  project. 
After  evacuation  the  opening  is  plugged  with  a  small  roll  of  well- 
oiled  gauze  and  kept  dilated  daily  until  healing  takes  place  and  all 
tendency  to  contraction  is  past. 

Species  III. — In  the  third  species  the  rectum  may  be  well 
formed  and  may  descend  into  the  pelvis  almost  far  enough  to  place 
the  case  in  species  II.,  or  the  interval  between  may  be  one,  two  or 
several  centimetres ;  or  the  rectum,  or  at  least  the  pouch  at  the  end 
of  the  intestine  may  terminate  at  or  above  the  pelvic  brim.  (Fig. 
216.)  The  space  between  the  pouch  and  the  perineum  may  be  filled 
with  cellular  tissue,  and  there  may  or  may  not  be  a  fibrous  cord 
extending  between  the  two  in  the  situation  where  the  rectum  should 
be.  My  own  experience  would  lead  me  to  believe  that  the  "  distinct 
fibrous  cord  "  often  described  is  absent  in  the  majority  of  cases,  or 
at  least  is  not  sufficiently  distinct  to  be  noticeable  as  a  guide  in  the 
search  for  the  rectal  pouch.  In  some  cases  the  pelvic  space  is  nar- 
row, and  the  tuberischii  can  be  demonstrated  as  closer  together 
than  normal.  In  other  cases  this  is  not  perceptible,  and  cellular 
tissue  fills  the  space  between  the  sacrum  and  coccyx,  and  the  bladder 
and  urethra,  or  uterus  and  vagina,  as  the  sex  may  be. 

Symptoms. — The  symptoms  are  uneasiness,  distress,  refusal  to 


THE    RECTUM    AND    ANUS  625 

take  the  breast,  straining,  distension  of  the  abdomen,  the  absence 
of  defecation,  and  in  some  cases  vomiting.  It  seems  strange  that 
vomiting  is  not  invariably  present  in  these  cases,  although  there  is 
complete  obstruction  of  the  intestinal  tract.  It  is  always  a  feature  of 
those  rare  cases  which  have  survived  more  than  seven  or  eight  days, 
even  during  several  weeks.  They  have  had  periodical  fecal  vomit- 
ing.    In  the  ordinary  case  vomiting  is  unusual. 

If  steps  are  not  taken  to  relieve  the  condition,  in  the  course  of  a 
few  days  the  abdominal  distension  may  become  extreme.  Tlie  child 
grunts  with  distress.  The  diaphragm  is  pressed  upward,  interfering 
with  respiration.  The  surface  of  the  body  becomes  purple  from  in- 
terference with  the  venous  return,  this  stasis  being  most  marked 
over  the  abdomen  and  lower  extremities.  The  straining  may  be 
severe  or  very  moderate  and  at  long  intervals  and  only  excited  by 
manipulation  of  the  abdomen.  The  infant  may  die  of  exhaustion; 
or  in  the  meantime  may  develop  paralysis  of  the  bowel  from  ex- 
treme distension  of  feces  and  gases;  or  gangrene  of  a  portion  of 
gut ;  rupture  of  the  colon ;  jaundice  ;  or  stercoremia  from  absorption 
of  toxines,  and  absence  of  elimination.  It  becomes  apathetic  and 
comatose  and  sinks  away. 

Diagnosis. — The  diagnosis  of  an  ano-rectal  malformation  is  so 
easily  made  upon  slight  examination  that  it  seems  strange  so  many 
cases  are  overlooked.  It  would  seem  that  every  physician  and  every 
nurse  must  recognize  the  serious  nature  of  such  malformation,  and 
yet  it  is  a  fact  that  the  majority  of  the  cases  do  not  come  to  the 
surgeon  until  several  days  after  birth,  when  there  is  distressing  dis- 
tension and  exhaustion,  the  meconium  has  become  septic,  and  per- 
haps peritonitis  or  other  complication  has  arisen,  or  even  gangrene 
or  perforation  has  taken  place.  One  must  conclude  that  no  exami- 
nation has  been  made  on  account  of  the  earlier  symptoms,  or  the 
condition  would  certainly  have  been  discovered.  As  to  the  diag- 
nosis of  the  exact  location  and  shape  of  the  rectal  ampulla,  that  is 
quite  a  different  and  difficult  matter.  It  may  be  possible  in  some 
instances  to  locate  a  distended  pouch  by  palpation  and  percussion 
over  the  abdomen.  But  usually  the  abdomen  is  so  distended,  at  least 
if  not  seen  early,  that  little  if  any  difference  on  the  two  sides  can  be 
detected.  One  can  by  no  means  be  certain  that  the  colon  termi- 
nates anywhere  in  its  usual  course  on  the  left  side,  and  one  has  seen 
a  case  in  which,  with  the  terminal  pouch  on  the  left  side,  the  external 
distension  w^as  greater  on  the  right.  One  has  observed,  however, 
a  greater  degree  of  venous  stasis  in  the  lower  extremity  upon  the 
side  corresponding  to  the  distended  fecal  pouch,  and  it  may  be  this 
symptom  is  of  some  value.  I  have  never  found  the  sound  intro- 
duced into  vagina,  urethra  or  bladder  to  be  of  any  use  in  determin- 
ing the  location  of  a  distended  pouch,  and  yet  it  should  be  tried  in 


626  SURGICAL   DISEASES    OF   CHILDREN 

all  cases.  The  passing  of  feces  with  urine  should  be  carefully  in- 
quired into;  and  search  made  for  any  fistulous  opening-  anywhere 
about  the  pelvic  region  or  at  the  umbilicus.  Bulging  during  strain- 
ing may  be  felt  over  the  perineum  if  the  rectal  pouch  is  at  all  near 
by.  Yet  it  is  very  difficult  to  determine  by  this  means  its  distance 
from  the  surface.  Unless  it  is  sufficiently  low  in  the  pelvis  to  cause 
an  impulse  or  bulging  on  straining  perceptible  to  the  finger  (or  per- 
haps to  a  probe  in  vagina  or  urethra),  I  regard  it  as  impossible  in 
these  cases  of  imperforate  anus  without  external  sinus  to  ascertain 
before  operation  the  degree  of  development  of  the  rectum  or  the 
location  of  the  enteric  termination. 

Prognosis. — The  prognosis  is  necessarily  very  serious.  With- 
out surgical  interference  the  infant  will  almost  certainly  perish  mis- 
erably within  a  few  days  or  a  week.  A  few  cases  are  on  record, 
for  example  one  by  Cripps,  in  which  the  infant  survived  several 
weeks.  But  these  cases  are  so  rare  as  to  count  nothing  in  the  prog- 
nosis. The  course  and  mode  of  death  have  been  mentioned  under 
symptoms.  The  prognosis  that  can  be  offered  in  case  of  operation, 
while  uncertain,  is  by  no  means  hopeless.  It  must  vary  with  the  time 
at  which  operation  is  undertaken,  the  condition  of  the  patient,  the 
degree  of  the  malformation  and  the  success  of  the  operator  in  es- 
tablishing an  opening  for  the  escape  of  intestinal  contents.  The 
later  the  operation  is  postponed  the  greater  the  danger.  Some  of 
the  complications  already  mentioned  are  necessarily  fatal.  Numer- 
ous cases  are  on  record  of  patients  operated  upon  sufficiently  early 
living  to  adult  life  with  as  great  comfort  and  happiness  as  if  they 
had  been  born  without  malformation.  The  surgeon  has  no  alterna- 
tive but  to  urge  operation  in  any  case  in  which  there  is  either  a  pos- 
sibility of  a  successful  result  or  in  which  death  can  be  averted  for 
the  time  being,  and  the  patient  thus  be  given  a  chance  for  his  life, 
even  though  further  surgical  attention  may  be  necessary  at  some 
later  period.  The  parents  have  no  right  to  decide  that  the  child  must 
die  rather  than  live  with  an  anus  in  an  unusual  position.  Neither 
can  operation  be  looked  upon  as  a  farther  infliction  of  suffering 
upon  the  infant,  for  it  affords  the  most  intense  relief  imaginable,  as 
all  who  have  handled  such  cases  can  testify. 

Treatment. — The  only  treatment  is  by  surgical  operation  to 
reach  and  empty  the  rectal  pouch.  If  this  can  be  done  so  as 
to  establish  a  permanent  opening  in  or  near  its  normal  situation,  so 
much  the  better.  And  if  the  opening  have  sphincter  control  the 
result  will  be  ideal.  Operation  should  be  undertaken  without  delay. 
Delay  inevitably  puts  the  patient  in  worse  condition.  Exhaustion, 
stercoremia,  and  distension  increase ;  the  meconium,  at  first  sterile, 
becomes  septic  and  the  results  or  complications  previously  mentioned 
are  likely  at  any  time  to   supervene.     There   is   no  possibility  of 


THE    RECTUM   AND    ANUS  627 

gaining  anything  by  more  delay  than  is  necessary  to  get  the  patient 
to  a  hospital  or  to  prepare  for  an  aseptic  operation. 

To  discuss  in  its  entirety  the  development  of  surgical  procedures 
in  these  cases  with  all  the  reasons  for  the  numerous  modifications 
that  have  brought  about  the  present  status  of  opinion  and  practice 
would  transcend  our  present  object.  There  are  numerous  elaborate 
articles  upon  the  subject.^ 

Of  the  older  methods  I  shall  mention  but  one  at  this  point, 
and  that  in  order  to  condemn  it.  Puncture  or  attempt  at  puncture 
of  the  rectal  pouch,  with  trocar  and  canula  or  aspirating  needle 
introduced  through  the  perineum,  suggests  itself  to  the  practi- 
tioner on  account  of  its  apparent  simplicity  and  its  bloodlessness. 
But  its  use  is  uncertain,  unsafe  and  unsatisfactory.  One  cannot 
be  sure  what  he  is  doing,  is  liable  to  injur^e  important  structures,  to 
penetrate  the  peritoneum,  to  infect  pelvis  or  peritoneum,  and  at 
the  best  can  only  temporarily  empty  the  pouch  if  it  is  found.  The 
records  of  past  experiences  condemn  this  procedure  in  unmistak- 
able terms. 

Infra-pelvic  Operations. — The  operation  of  choice  with  the 
patient  in  fair  condition  is  perineal  proctoplasty  by  incision  in  the 
middle  line  of  the  perineum.  (Amussat,  1835.)  Anesthesia  is 
not  necessary  with  the  patient  in  good  condition,  or  at  most  a  few 
whififs  of  chloroform  for  the  skin  incision.  Anesthesia  is  a  positive 
disadvantage,  since  it  stops  the  straining  which  enables  one  to  feel 
by  the  increased  tension  during  the  expulsive  effort,  when  he  is  in 
proximity  to  the  distended  ampulla.  Pressure  of  the  hand  over 
the  hypogastrium  will  imitate  straining,  but,  the  diaphragm  not 
being  fixed,  is  not  so  effectual.  Moreover,  in  bad  cases  seen  late, 
with  tympanites  interfering  with  the  respiration,  with  stercoremia 
and  approaching  exhaustion,  anesthesia  increases  the  danger. 

The  position  of  the  patient  during  operation  is  an  exaggerated 
lithotomy  position.  (Matas.)  The  incision  should  begin  as  far 
forward  as  the  scrotum  or  vulvar  commissure  will  allow,  and 
keeping  strictly  in  the  middle  line  should  extend  backward  to  the 
tip  of  the  coccyx.  This  incision  will  go  deep  enough  to  enable  the 
index  finger  to  pass  through  the  muscles  of  the  pelvic  floor,  when 
it  may  encounter  the  rectal  pouch  or  feel  its  proximity  during  strain- 
ing. If  the  pouch  is  not  found  here  the  dissection  should  be  car- 
ried further  up,  still  keeping  in  the  middle  line,  and  near  the  sacrum 
and  pausing  every  moment  to  explore  with  the  finger.  If  the  rec- 
tum is  found  it  should  be  loosened  by  careful  dissection  from  its 
surroundings  and  pulled  down  into  the  opening  and  stretched  to 
the  margins  of  the  incision  and  opened.  Some  operators  advise 
opening  the  pouch  before  attempting  to   dissect   it  loose.     But  it 

^  Notably    admirable    contributions    by    Matas    among    recent    writers. 


628  SURGICAL   DISEASES    OF    CHILDREN 

will  be  found  easier  to  distinguish  by  touch  between  the  pouch  and 
its  surrounding  tissues  before  it  is  opened  than  afterward.  Be- 
sides, the  efforts  at  straining  tend  to  drive  the  distended  pouch 
down  into  the  opening.  However,  when  it  has  be,en  loosened  as 
much  as  possible  and  does  not  reach  the  margins  of  the  incision, 
it  may  be  opened  and  pulled  down.  It  may  now  be  found  to  reach. 
If  the  intestinal  tissue  is  still  too  short,  it  will  be  necessary  to  carry 
the  external  incision  farther  back  through  the  middle  line  of  the 
coccyx.  The  coccyx  can  easily  be  divided  by  knife  or  scissors,  as 
it  is  cartilaginous.  By  thus  placing  the  external  opening  higher  up 
and  dragging  the  rectum  down  the  latter  may  be  securely  sutured 
to  the  outer  margins  of  the  wound  from  which  the  integument  has 
been  remoyed  in  a  narrow  circle.  But  if  the  operator  has  not  been 
able  to  reach  the  ampulla  through  the  perineal  incision,  what  shall 
be  done?  If  the  patient  is  a  fairly  strong  child  and  still  in  good 
condition,  he  should  be  turned  upon  his  face  and  the  perineal  inci- 
sion carried  backward  in  the  median  line  through  the  coccyx 
(median  coccygotomy),  and  the  dissection  carried  upward,  in 
front  of  the  sacrum,  as  far  as  can  be  by  sight  and  touch,  from  this 
opening.  If  it  proves  necessary  to  explore  still  higher,  the  incision 
can  be  extended  through  the  sacrum  to  the  level  of  the  lower  bor- 
der of  the  third  sacral  foramen  (median  sacro-coccygotomy,  Vin- 
cent, 1887).  The  lower  border  of  the  third  sacral  foramen  is  situ- 
ated one  and  a  quarter  centimetres  above  the  sacro-coccygeal  joint 
(Matas).  One  might  venture  to  carry  a  median  incision  one  cen- 
timetre higher  than  this  point,  but  not  to  make  a  cross  section  of 
the  sacrum  at  a  level  higher  than  the  lower  border  of  the  third 
sacral  foramen  for  fear  of  leaving  open  the  sacral  canal  and  of 
injuring  the  nerve  supply  to  the  bladder.  Through  such  a  median 
incision,  the  sides  of  which  are  held  open  with  retractors,  the  ex- 
ploration can  be  continued.  If  more  room  is  necessary  for  the 
exploration,  or  if  the  ampulla  is  found  and  more  freedom  is  needed 
for  its  dissection,  the  sacrum  can  be  cut  across  by  a  transverse  in- 
cision at  right  angles  to  the  original  median  incision  and  at  the 
level  before  stated  as  the  limit  of  safety.  (T  section,  Morestin, 
1894.)  Two  triangular  flaps  can  then  be  pulled  outward,  making 
an  opening  that  is  ample  for  whatever  is  to  be  done.  The  rectal 
pouch  having  been  loosened,  should  be  brought  into  the  opening, 
as  low  as  it  will  reach,  and  there  secured  by  sutures  as  before  de- 
scribed, making  an  artificial  anus.  If  possible,  this  anus  should 
be  located  below  the  level  of  the  levator  muscles  to  secure  control 
of  the  evacuations.  But  if  it  must  be  located  higher  than  the 
levators,  Gersuny's  procedure  should  be  resorted  to ;  that  is,  the 
rectum  should  be  rotated  axially  before  it  is  sutured  to  the  mar- 
gins of  the  incision.     The  amount  of  twisting  required  is  usually 


THE    RECTUM    AND    ANUS  629 

from  120  degrees  to  270  degrees.  The  open  extremity  of  the  gut 
should  simply  be  twisted  upon  itself  until  the  finger  when  intro- 
duced feels  a  sphincter-like  resistance.  The  edges  of  the  gut  should 
then  be  secured  to  the  edges  of  the  skin  wound  by  two  rows  of 
sutures,  the  muscular  as  well  as  the  mucous  coats  being  held  in 
the  sutures,  which  should  be  firm  enough  to  prevent  the  bowel 
freeing  itself  or  untwisting. 

AbdoDiinal  Operations. — Abdominal  section  is  not  the  first 
choice  in  a  case  of  ano-rectal  imperforation  without  sinus.  But  it 
would  be  resorted  to  under  certain  conditions,  namely:  If  the  pa- 
tient were  in  such  extreme  jeopardy  from  abdominal  distension 
and  exhaustion  that  prompt  relief  must  be  afforded  with  the  least 
possible  operative  traumatism  and  shock ;  or  if  the  infra-pelvic 
route  had  been  tried  with  no  success  in  locating  the  enteron ;  then 
one  should  proceed  to  form  a  fecal  fistula.  Unless  there  were  some 
good  reason  for  a  different  location  for  this  fistula,  such  as  a  dis- 
tinct bulging  or  fluctuation  at  a  certain  point  upon  the  abdomen,  one 
would  select  the  site  about  two  finger  breadths  (of  the  patient) 
aboye  the  middle  and  parallel  with  Poupart's  ligament  on  the  left 
side.  A  small  incision  is  made  and  the  nearest  distended  coil  of  in- 
testine is  rapidly  sewed  through  its  serous  and  muscular  coats  into 
the  wound  with  running  sutures  of  catgut,  all  round  the  margins 
of  the  incision,  a  row  of  sutures  to  the  peritoneum  and  another  row 
to  the  fascia  and  skin.  The  gut  is  then  opened  and  its  contents 
discharged.  The  bowel  opened  may  fortunately  prove  to  be  the 
rectal  pouch  or  the  colon  (inguinal  colostomy,  Littre,  McCormac), 
or  a  small  intestine  (enterostomy,  Nelaton).  If  the  child  survive 
and  become  sufficiently  vigorous,  at  some  future  time  operation  may 
again  be  undertaken.  This  operation  will  be  planned  according  to 
the  nature  of  the  malformation.  If  the  fecal  fistula  previously  made 
communicates  with  the  colon  a  perineal  anus  may  be  formed  by  in- 
troducing a  sound  at  the  fistula  and  pressing  the  sac  down  toward 
an  incision  made  in  the  infra-pelvic  region.  (Chassaignac,  1856.) 
The  fistulous  opening  in  the  groin  may  then  be  closed.  But  if  the 
fecal  fistula  connect  with  a  small  intestine  a  subsequent  laparotomy 
will  be  made  to  determine  the  deformity  and  either  bring  the  terminal 
end  of  the  intestine  to  the  perineal  region,  or  to  form  a  permanent 
artificial  anus  in  the  groin.  The  question  of  a  primary  exploratory 
laparotomy  has  been  much  discussed,  but  the  weight  of  evidence  is 
in  favor  of  the  perineo-sacro-coccygeal  route  if  the  patient  is  in 
fit  condition.  (Matas.)  If,  however,  for  the  sake  of  quick  and 
certain  relief,  the  abdominal  route  is  chosen  for  the  primary  opera- 
tion, it  is  advised  by  some  operators,  instead  of  immediately  making 
a  colostomy  in  the  groin,  to  open  the  abdomen  in  the  left  semilunar 
line  and  if  possible  ascertain  the  relations  of  the  rectal  pouch,  so 


630  SURGICAL   DISEASES    OF   CHILDREN 

as  to  determine  whether  a  fecal  fistula  or  a  permanent  artificial  anus 
upon  the  abdomen  should  be  produced.  The  operator  is  warned, 
however,  that  in  the  distended  and  tympanitic  state  of  the  abdomen 
such  an  exploration  is  likely  to  be  very  unsatisfactory  without 
greater  exposure  and  manipulation  of  the  intestines  than  the  infant 
is  able  to  endure.  My  own  preference  is  for  the  infra-pelvic  as  the 
primary  operation,  if  necessary  making  the  sacro-coccygotomy.  If 
the  rectal  pouch  cannot  be  found  by  subperitoneal  search,  the  peri- 
toneum should  be  opened  through  the  pelvis  and  the  pouch  sought 
higher  up.  (Stromeyer,  1844.)  If  found,  the  pouch  is  to  be  drawn 
into  the  sacro-coccygeal  wound  and  there  secured.  If  not,  there 
remains  the  plan  of  opening  the  abdomen  either  in  the  median  line 
or  laterally  and  bringing  down  the  pouch  into  the  perineal  or  sacral 
opening.  (McLeod,  1879.)  ^^t  I  here  repeat  the  advice  that  if 
either  before  beginning  any  operative  procedure,  or  during  the  per- 
formance of  one  of  the  more  radical  operations  for  permanent  relief 
from  the  malformation,  it  be  observed  that  the  patient  is  not  in  con- 
dition to  withstand  any  considerable  shock,  a  fecal  fistula  should  be 
rapidly  produced  in  the  inguinal  region  for  temporary  relief,  and 
the  permanent  correction  postponed  to  a  more  favorable  time.  There 
remains  only  to  be  mentioned  in  this  connection  drainage  of  the 
cecum  in  the  right  inguinal  region  when  the  rectum  and  colon 
are  entirely  absent.     (Pillore.) 

When  the  operator  has,  by  any  of  these  routes  or  methods,  suc- 
ceeded in  reaching  and  emptying  the  distended  intestinal  pouch,  the 
babe  shows  evidence  of  the  greatest  possible  relief  and  satisfaction. 
The  straining  ceases,  the  distress  gives  way  to  quiet  rest,  the  infant 
takes  the  breast  or  drink  eagerly  and  sleeps  peacefully. 

Species  IV. — In  the  fourth  species  (Fig.  217)  the  septum  may 
be  thin  or  thick,  or  its  place  may  be  taken  by  an  impervious  cord- 
like structure  substituting  a  portion  of  the  rectum,  or  the  rectal  pouch 
may  be  located  at  a  distance,  or  the  anus  may  open  into  the  vagina 
posteriorly.     (Fig.  218.) 

Symptoms. — The  symptoms  are  the  same  as  have  been  described 
under  Species  III. 

Diagnosis. — The  external  appearances  of  this  form  are  so  de- 
ceptive that  the  condition  is  likely  to  go  undiscovered  by  mother  or 
nurse.  When  the  symptoms  have  led  to  examination  by  the  sur- 
geon's finger  or  probe  the  condition  is  revealed. 

Treatment. — The  line  of  treatment  is  the  same  as  that  described 
for  Species  III,  with  the  exception  that  the  lining  of  the  anal  thimble 
should  be  removed  when  the  gut  is  brought  down  to  be  sutured  to 
the  margin  of  the  anus.  It  is  not  satisfactory  in  these  cases,  even  if 
there  is  only  a  septum  at  a  distance  within  the  anus,  to  merely  divide 
the  septum  and  dilate.     Recontraction  will  persistently  take  place. 


THE    RECTUM   AND   ANUS 


631 


The  gut  should  be  brought  down,  as  before  described,  so  that  the 
whole  canal  is,  to  the  anal  margin,  furnished  with  a  mucous  lining. 
Species  V.  (See  Fig.  219.)— Fig.  224  also  shows  a  case  of 
the  fifth  species.  The  infant  was  otherwise  well  formed,  weighed 
7i  pounds,  and  measured  2i|  inches  in  length.  The  anus  was  absent, 
its  place  being  occupied  by  a  slight  groove.  A  median  cleft  partly 
separated  the  scrotum  into  lateral  halves  with  a  testicle  in  each.  At 
the  bottom  of  this  cleft,  half  an  inch  posterior  to  the  peno-scrotal 
junction,  were  two  small  orifices.    One  of  these  extended  onlv  skin 


Fig.  224.  Malformation  of  the  rectum.  Anus  absent.  A  grouve  partly 
divides  the  scrotum  in  the  median  Hne.  In  the  groove  near  the  peno- 
scrotal junction  is  the  orifice  of  a  sinus.  Note  the  distension  of  the 
abdomen  and  discoloration  of  the  skin.  The  malformed  bowel  is  shown 
in  Fig.  225. 

deep,  the  other  deeper.  Meconium-stained  fluid  and  a  small  amount 
of  gas  occasionally  escaped  from  the  deeper  sinus.  The  finest  fili- 
form bougie  or  canaliculus  probe  could  not  penetrate  this  sinus  more 
than  an  inch.  The  distension  of  the  abdomen  and  the  discoloration 
of  the  skin  from  venous  stasis  are  also  shown.  On  the  left  side  is 
a  fecal  fistula  located  higher  than  usual  on  account  of  swelling  and 
fluctuation  in  that  situation.  Fig.  225  shows  the  internal  malforma- 
tion. The  cecum  with  the  appendix  behind  it  was  located  half  way 
from  the  umbilicus  to  the  cartilages  of  the  ribs  on  the  right  side. 
Thence  the  colon  extended  transversely  to  the  left,  made  the  splenic 
flexure,  then  turned  to  the  right  and  crossed  the  abdomen  at  the 
level  of  the  umbilicus  to  a  large  pouch  which  occupied  the  usual 
position  of  the  cecum.  This  pouch  extended  beyond  the  median 
line  and  was  closely  attached  to  the  bladder.    It  was  rounded  in  out- 


6.32 


SURGICAL   DISEASES    OF   CHILDREN 


Fig.  225.  Malformed  bowel  from  the  case  shown  in  Fig.  224.  The  speci- 
men is  greatly  shrunken  by  the  preserve.  The  enormous  pouch  occupied 
the  right  hypogastrium  and  terminated  in  a  minute  sinus  to  the  right 
of  and  posterior  to  the  urethra.  The  grooved  director  is  thrust  through 
the  urethra.  The  two  probes  mark  the  inner  and  outer  openings  of 
the  sinus. 


THE    RECTUM    AND    ANUS  633 

line  but  came  lo  a  funnel-shaped  tapering  end  in  proximity  to  the 
neck  of  the  bladder  at  the  right  and  posteriorly  to  the  urethra.  The 
funnel  point  extended  toward  the  fistula  in  the  scrotum  and  was 
doubtless  continuous  with  it  although  too  fine  to  be  penetrated  by  a 
probe. 

The  fistulous  opening  in  such  cases,  as  indicated  in  the  heading, 
may  open  at  any  point  along  the  raphe  of  the  perineum  or  scrotum 
under  the  prepuce,  or  about  the  symphisis  pubis  or  elsewhere. 

SyniptoDis. — The  symptoms  vary  with  the  degree  of  occlusion. 
They  may  be  those  detailed  under  Species  III,  or  are  modified  by 
the  escape  of  meconium  and  gases  through  a  sufficiently  patent 
fistula. 

Diagnosis. — The  diagnosis  is  not  difficult  in  view  of  the  symp- 
toms and  the  presence  of  a  fistula  which,  if  patulous,  gives  the 
surgeon  a  clue  to  the  location  of  the  rectal  pouch. 

Prognosis. — The  prognosis  in  these  cases  as  a  class  is  more 
favorable  than  in  complete  occlusion  without  a  sinus ;  for  the  reason 
that  the  sinus  may  afford  a  measure  of  relief  from  the  obstruction 
by  escape  of  intestinal  contents,  and  also  may  guide  the  surgeon  in 
his  operation.  Cases  having  a  sufficiently  large  sinus  may  live  out 
the  expectancy  of  life  without  suffering  greatly  from  their  mal- 
formation. If  the  sinus  is  small,  tortuous,  or  impenetrable,  the  case 
is  scarcely  better  off  than  one  of  Species  III. 

Treatment. — If  the  fistulous  opening  is  sufficiently  large,  or  if 
it  can  be  made  so  by  dilatation,  to  afford  escape  of  feces,  the  case 
may  wait  for  a  time.  If  the  opening  is  not  situated  in  a  convenient 
location  for  a  permanent  anus,  when  the  child  is  in  good  condition 
for  operation  an  endeavor  may  be  made  to  establish  an  anus  in  the 
perineal  or  sacral  region,  as  before  described.  The  fistula  can  subse- 
quently be  closed.  If  the  fistula  is  too  small  to  be  of  any  use  froiii 
the  first  as  an  anus,  the  case  must  be  dealt  with  as  one  of  complete 
occlusion,  using  the  sinus  if  possible  for  sounding  to  ascertain  the 
situation  of  the  pouch  and  guiding  it  down  into  the  pelvis. 

Species  VL — The  sixth  species  is  the  commonest  of  all.  The 
varieties  are  sometimes  named  according  to  the  point  of  termination 
of  the  rectal  opening — as  atresia  ani  vaginalis  (Fig.  220),  atresia  ani 
vesicalis,  atresia  ani  urethralis.  By  some  pathologists  this  malforma- 
tion is  considered  a  tendency  to  reversion  to  the  cloacal  type  of  lower 
animals ;  but  its  occurrence  is  easily  explained  as  an  error  in 
the  differentiation  of  the  genito-urinary  from  the  intestinal  por- 
tion of  the  tube  which  was  early  in  embryonal  life  common  to 
both. 

Atresia  ani  vaginalis  is  the  most  frequently  met  of  any  va- 
riety of  this  species.  The  opening  into  the  vagina  may  be  large  or 
small  and  may  be  located  just  within  the  fourchctte. 


634  SURGICAL   DISEASES    OF   CHILDREN 

Symptoms. — The  symptoms  will  vary  according  to  the  size  of 
the  rectal  outlet.  There  may  be  symptoms  of  a  serious  obstruction 
or  there  may  be  no  symptoms  at  all  to  attract  attention. 

Diagnosis. — The  diagnosis  is  readily  made  by  noting  that  the 
anus  is  absent  and  that  meconium  or  feces  issue  from  the  vaginal 
orifice. 

Prognosis  in  this  variety  is  favorable  both  as  regards  life,  and 
the  probability  of  successful  correction  of  the  malformation  if 
this  is  necessary.  It  may  cause  no  inconvenience  of  any  conse- 
quence. 

Treatment. — If  the  opening  is  large  enough  or  can  be  somewhat 
dilated  so  that  the  malformation  causes  no  discomfort,  the  patient 
may  well  be  left  to  grow  larger  and  stronger  before  operation  is 
considered.  Operation  for  correction  of  this  malformation  may  be 
done  by  one  of  two  principal  methods.  First,  a  sound  suitably  curved 
may  be  introduced  through  the  vaginal  opening  into  the  rectum  and 
directed  in  such  a  manner  that  its  end  is  made  to  project  near  the 
normal  site  for  the  anus.  This  is  then  cut  down  upon  from  the  out- 
side, the  rectum  dissected  loose,  brought  down  into  the  perineal 
opening,  incised,  and  the  margins  of  the  incision  in  the  gut  sutured 
to  the  margins  of  the  skin  incision.  The  fistulous  opening  into  the 
vagina  may  subsequently  be  closed  if  necessary.  Second,  the  mal- 
formation may  be  corrected  by  dissecting  out  the  end  of  the  rectum, 
together  with  its  opening  into  the  vagina,  and  transplanting  it  entirely 
into  a  new  situation  with  the  opening  in  the  perineum  (Rizzoli). 
The  vaginal  wound  is  then  closed  by  sutures. 

Atresia  Ani  Vesicalis  (Fig.  221). — In  this  variety  the  rectum 
communicates  with  the  bladder,  by  either  a  large  or  a  small  opening. 

Symptoms. — In  addition  to  the  symptoms  of  obstruction  already 
fully  described  under  Species  III,  there  is  passage  of  urine  mixed 
with  meconium  or  fecal  matter. 

Diagnosis  is  made  by  absence  of  the  anus,  distension  of  abdo- 
men, straining  and  other  symptoms  of  intestinal  occlusion  and  pass- 
age of  urine  mixed  with  fecal  matter  or  meconium.  Feces  or  meco- 
nium are  not  passed  without  urine. 

Prognosis. — In  this  form  of  malformation  one  gives  a  very 
guarded  prognosis.  The  fact  that  the  rectum  opens  into  the  bladder, 
which  in  the  infant  is  an  abdominal  organ,  proves  that  the  rectal 
pouch  is  situated  very  high.  Inflammation  of  the  bladder  is  sure  to 
occur  in  time,  or  complete  obstruction  to  supervene  at  any  time  the 
feces  become  bulky. 

Treatment. — In  a  female  infant  dilatation  of  the  urethra,  and 
in  a  male  infant  dilatation  with  incision  as  in  lithotomy,  might  give 
temporary  relief  from  the  obstruction,  and  these  methods  of  treat- 
ment were  formerly  in  use.    Yet  the  relief  afforded  would  only  be 


THE    RECTUM   AND    ANUS  635 

doubtful  and  temporary.  A  more  effectual  method  should  be  under- 
taken. One  might  well  hesitate  between  the  infra-pelvic  and  the 
abdominal  routes.  If  the  infant  were  large  and  vigorous  I  would 
make  an  attempt  by  sacro-coccygotomy,  reserving  laparotomy  as  a 
last  resort.  But  if  the  babe  were  less  robust  or  in  an  exhausted  con- 
dition I  would  attempt  nothing  more  than  an  ing'uinal  colostomy  for 
immediate  relief ;  and  at  a  subsequent  time,  if  exploration  through 
the  external  fecal  fistula  gave  promise  of  success,  one  could  separate 
by  ligatures  the  colon  below  the  external  fecal  fistula  from  that  por- 
tion connected  with  the  bladder,  causing  the  external  fistula  to  be- 
come a  permanent  artificial  anus,  and  the  colon  below  it  to  become 
obliterated. 

Atresia  Ani  Urethralis. — In  this  malformation  the  rectum 
communicates  with  some  part  of  the  urethra.     (Fig.  222.) 

Symptoms  and  Diagnosis  are  the  same  as  with  the  previous  va- 
riety excepting  that  meconium  or  feces  is  sometimes  passed  from 
the  urethra  without  the  admixture  of  urine,  and  between  the  times 
of  urination. 

Prognosis. — Prognosis  is  more  unfavorable  than  in  the  previous 
variety  so  far  as  concerns  danger  from  immediate  obstruction ;  but 
rather  better  with  regard  to  reaching  the  rectal  pouch  by  the  infra- 
pelvic  route,  for  the  pouch  probably  descends  farther  than  in  atresia 
ani  vesicalis. 

Treatment. — The  treatment  is  perineo-coccygotomy  or  sacro- 
coccygotomy  with  the  establishment  if  possible  of  an  anus  in  that 
situation.  Failing  in  this  attempt,  inguinal  colostomy,  followed  by 
obliteration  of  the  lower  end  of  the  colon  with  its  urethral  communi- 
cation as  suggested  in  the  previous  section. 

Species  VII. — The  seventh  species  of  this  malformation  does 
not  endanger  the  life  of  the  child  and  may  be  left  to  be  dealt  with 
when  It  is  older  and  stronger  and  the  parts  are  larger.  If  the  ureters 
end  in  the  bladder  the  condition  would  as  well  not  be  meddled  with. 
If  vagina  or  uterus  open  into  the  bladder,  when  the  girl  is  larger 
the  generative  organs  can  probably  be  separated  and  the  opening 
between  them  and  the  rectum  closed  successfully. 

Species  VIII. — This  species,  in  which  the  rectum  is  entirely 
absent,  might  about  as  well  have  been  classified  as  a  variety  of 
Species  III,  as  it  differs  only  in  the  amount  of  rectum  that  is  want- 
ing. Symptoms  are  the  same  as  in  Species  III,  and  the  diagnosis 
cannot  be  made  until  exploration  by  the  sacro-coccygeal  route  fails 
to  find  the  rectum.  Treatment  is  by  laparo-colotomy  and  the  forma- 
tion of  a  permanent  artificial  anus. 

Species  IX. — In  the  ninth  specioe  the  symptoms  are  those  of 
more  or  less  obstruction,  varying  with  the  freedom  of  the  outlet.  The 
fistulous  opening  may,  if  necessary,  be  dilated  or  possibly  trans- 


6z6  SURGICAL   DISEASES    OF    CHILDREN 

planted,  or  an  artificial  anus  formed  in  a  more  advantageous  situa- 
tion. But  usually  there  is  little  to  be  done  for  these  cases  beyond 
securing  a  free  outlet  for  feces. 

PROLAPSUS   OF  THE  RECTUM 

This  is  a  very  common  affection  in  infancy  and  especially  in 
childhood,  and  is  sometimes  quite  troublesome.  It  consists  in  a  pro- 
trusion of  the  lower  portion  of  the  rectum  through  the  anus.  The 
protruded  portion  may  consist  only  of  the  mucous  lining  of  the  lower 
portion  of  the  rectum ;  or  of  the  entire  thickness  of  the  walls  of  the 
rectum.  Sometimes  a  third  variety  is  described  in  which  the  upper 
portion  of  the  rectum  is  invaginated  into  the  lower  and  protrudes 
at  the  anus ;  but  this  is  really  a  variety  of  intussusception,  and  should 
not  be  classed  with  prolapsus.  The  large  size  of  the  rectum  and  its 
straightness,  together  with  the  looseness  of  its  mucous  and  sub- 
mucous tissues,  and  especially  the  straightness  of  the  coccyx,  un- 
doubtedly act  as  predisposing  causes  of  prolapsus.  Also  malnutri- 
tion, and  any  acute  or  chronic  condition  which  lowers  the  muscular 
tone,  favoring  relaxation  of  the  sphincters  and  levators ;  also  lack  of 
adipose  tissue.  As  exciting  causes  may  be  mentioned  anything 
which  excites  tenesmus,  such  as  diarrhea,  especially  dysentery,  or 
constipation,  or  mere  frequency  of  defecation,  or  rectal  polypus, 
the  oxyuris,  phimosis,  or  a  narrow  urethral  orifice,  vesical  calculus, 
or  violent  or  prolonged  straining  with  the  sphincter  involuntarily 
relaxed  as  occurs  in  the  paroxysms  of  whooping-cough ;  or  the  con- 
gestion of  the  hemorrhoidal  vessels  and  the  prolonged  bearing  down 
that  occur  when  predisposed  children  are  allowed  to  sit  a  long  time 
on  the  nursery  chair  or  a  chamber-vessel  in  a  position  that  favors 
straining. 

Symptoms. — The  characteristic  symptom  is  the  protrusion  at 
the  anus  of  a  purplish-red  mass  covered  with  swollen  mucous  mem- 
brane, during  or  after  defecation,  urination,  or  a  paroxysm  of  cough- 
ing, or  sometimes,  in  bad  cases,  when  none  of  these  have  taken  place. 
Usually  there  is  no  complaint  of  pain,  and  often  the  projection  dis- 
appears as  soon  as  the  child  ceases  straining  or  stands  up.  The 
protrusion  may  be  only  a  slight  ring  at  the  margin  of  the  anus,  or 
it  may  be  a  mass  of  the  size  of  the  child's  fist  and  extend  an  inch 
or  more.  Cases  of  ulceration,  even  of  sloughing,  of  peritonitis  and 
death  from  this  same  cause  have  been  reported,  but  such  have  never 
come  under  my  care. 

Diagnosis. — The  diagnosis  is  very  readily  made  if  one  sees  the 
protrusion,  and  it  can  be  made  without  difficulty  from  the  history 
and  an  examination  without  seeing  the  protrusion.  The  conditions 
which  could  be  confounded  with  prolapsus  of  the  rectum  are  hemor- 
rhoids, polypus,  intussusception,  and  nevus.     Hemorrhoids  are  ex- 


THE    RECTUM    AND    ANUS  637 

tremely  rare  in  children,  while  prolapsus  is  common.  Polypus  could 
be  recognized  by  its  globular  pedunculated  form,  if  seen  when  pro- 
lapsed or  if  felt  with  the  finger  within  the  rectum.  Intussusception 
gives  a  different  history ;  but  even  if  the  history  was  indefinite  the 
two  conditions  could  be  differentiated  by  examination  when  the 
tumor  projected  at  the  anus.  Both  present  a  purplish  mass  covered 
with  the  rugous  mucous  membrane  very  much  congested,  and  both 
have  a  central  opening  at  the  apex  of  the  mass.  But  with  the  intus- 
susception one  can  introduce  a  finger  between  the  tumor  and  the  anal 
margin  and  sweep  it  entirely  around  between  the  tumor  and  the 
sphincter  or  rectal  lining.  With  prolapsus  the  tumor  merges  into 
the  anal  margin  itself.  Nevus  located  just  within  the  rectum  or 
at  the  ano-rectal  margin  I  have  known  to  be  mistaken  for  prolapsus 
and  for  hemorrhoids,  and  again  to  be  complicated  with  prolapsus 
which  it  probably  helped  to  produce.  Nevus  would  usually  be  dif- 
ferentiated if  borne  in  mind  during  the  examination. 

Treatment. — The  treatment  of  a  prolapsing  rectum  during  the 
prolapsus  is  to  immediately  return  the  protrusion  within  the  sphinc- 
ter. This  can  generally  be  done  in  a  moment  by  laying  the  patient 
on  his  side,  or  across  one's  knees  and  gently  pressing  the  entire  mass 
in  with  the  fingers.  A  soft  towel  or  napkin,  wet  with  water  or 
well  smeared  with  vaseline,  placed  next  to  the  mass  while  pressure 
is  made,  facilitates  the  procedure.  To  push  up  the  central  portion 
of  the  protrusion  first  makes  it  recede  more  easily.  Difficulty  is 
seldom  experienced  unless  the  bowel  has  been  out  a  long  time  and 
become  inflamed  and  the  sphincter  very  tight.  If  necessary  an 
anesthetic  could  be  employed.  After  the  reduction  the  anus  should 
be  covered  with  a  muslin  pad  held  by  a  T  bandage  and  the  child 
kept  recumbent  for  an  hour  or  so.  Means  must  now  be  instituted 
to  prevent  the  recurrence  of  the  prolapse.  The  cause  of  straining, 
whatever  it  is — calculus,  phimosis,  constipation,  over-feeding,  bad 
feeding,  worms,  polypus — is  to  be  removed.  The  child  should  never 
be  allowed  to  sit  and  strain  at  stool.  He  should  be  required  to  def- 
ecate while  in  the  recumbent  position ;  or  in  some  mild  cases  the 
mother  or  nurse  may  hold  the  child  in  her  hands,  one  hand  under 
each  buttock,  and  drawing  the  skin  across  the  anus  upon  one  side. 
In  some  cases  it  may  be  necessary  for  the  child  to  wear  a  T  bandage 
and  compress  continuously,  or  a  wide  strip  of  adhesive  plaster  across 
the  nates,  squeezing  them  together  and  so  supporting  the  anus. 
Enemata  of  astringent  solutions,  such  as  a  drachm  of  tannic  acid 
or  of  the  dark  fluid  extract  of  witch-hazel  or  of  alum,  to  4  ounces 
of  water,  may  be  employed  daily  when  the  mucous  lining  is  relaxed. 
Enemata  of  cold  water,  even  ice  water,  an  ounce  or  two  at  a  time, 
have  a  tonic  effect.  Astringent  suppositories  have  been  recom- 
mended, but  their  effect  is  too  narrowly  localized  to  be  of  much  use 


638  SURGICAL   DISEASES    OF   CHILDREN 

unless  they  are  quite  powerful,  and  then  the  effect  is  difficult  to 
gauge.  Suppositories  of  nux  vomica  and  ergot  are  also  recom- 
mended. One  would  prefer  to  use  the  nux  vomica  internally  in  suit- 
able doses  as  a  tonic.  For  this  purpose  it  is  especially  useful  in  debil- 
itated children  with  relaxed  musculature.  Some  use  hypodermics  of 
strychnia  locally  once  or  twice  daily. 

Operative  measures  for  the  cure  of  rectal  prolapse  by  amputa- 
tion of  the  projecting  portion,  or  by  clamp  and  cautery,  or  by  colo- 
pexy,  or  by  Verneuil's  operation  of  exposing  the  rectum  posteriorly 
beneath  the  coccyx  and  narrowing  its  lumen,  are  not  needed  in 
children.  It  is  extremely  seldom  that  any  severe  treatment  is  neces- 
sary. In  chronic  and  obstinate  cases  cauterization  with  nitric  acid, 
of  the  portion  of  mucous  membrane  usually  protruded,  is  recom- 
mended by  good  authority.  The  directions  given  are,  to  paint  the 
whole  surface  of  the  mucous  membrane  with  a  swab  dipped  in  nitric 
acid,  apply  a  plug  of  oiled  cotton  or  gauze  and  reduce  the  whole 
into  the  rectum.  I  do  not  like  to  cauterize  and  consequently  scar 
so  heroically,  such  a  large  area  of  the  mucous  lining ;  and  have  suc- 
ceeded in  getting  a  satisfactory  effect  by  drying  the  mucous  lining 
carefully  with  gauze  sponges  and  drawing  the  glass  rod  or  very 
narrow  cotton-wrapped  applicator  dipped  in  the  nitric  acid,  in 
longitudinal  lines  upon  the  mucous  protrusion,  ending  below  within 
the  muco-cutaneous  margin,  leaving  a  half-inch  or  more  of  un- 
touched surface  between  each  two  lines.  Sometimes  only  two  or 
three  lines  of  cauterization  are  enough.  The  point  of  the  Paquelin 
cautery  is  convenient  to  use,  and  efficient,  making  lines  about  f  of 
an  inch  apart.  Power  dissects  off  a  spiral  strip  of  mucous  mem- 
brane, not  going  deeply,  lest  hemorrhage  occur.  One  would  prefer 
this  to  extensive  cauterization.  Of  course,  for  any  of  these  pro- 
cedures, the  bowels  must  be  previously  emptied  and  irrigated,  and  an 
anesthetic  be  used.  An  opium  and  belladonna  suppository  after  the 
operation  will  quiet  the  pain.  A  suppository  containing  ^  of  a  grain 
to  a  grain  of  cocaine  will  quiet  the  pain  more  promptly. 

NEVUS  OF  THE  RECTUM 

Nevus  of  the  rectum  has  been  reported  in  rare  cases.  It  pre- 
sents the  spongy  compressible  and  erectile  characteristics  of  nevus 
upon  the  skin,  its  surface  modified  by  the  covering  of  mucous  mem- 
brane. It  is  troublesome  by  its  bulk  and  tendency  to  produce  strain- 
ing, or  by  hemorrhage  that  takes  place  when  it  is  ulcerated.  The 
diagnosis  from  hemorrhoids  is  made  by  the  circumscribed  form  of 
the  latter. 

Treatment. — Treatment  is  by  the  galvanic  needles  or  by  the 
Paquelin  cautery.  The  treatment  by  ligature,  injections  of  iron 
or  other  astringent,  and  the  like,  are  no  longer  in  use  for  nevus  in 


THE    RECTUM    AND    ANUS  639 

any  situation  and  would  be  extremely  awkward  as  well  as  dangerous 
in  the  rectum.  The  galvanic  needles  are  not  only  safe  but  convenient. 
The  Paquelin  is  more  rapidly  used  upon  a  large  nevus.  Treatment 
by  injection  of  scalding  hot  sterile  water,  which  is  a  very  efficient 
means  upon  nevi  elsewhere,  I  have  not  had  an  opportunity  to  try 
in  nevus  of  the  rectum,  but  shall  do  so.  (See  also  Angioma  in 
Chapter  on  Tumors.) 

POLYPUS   OF  THE   RECTUM 

This  is  not  uncommon  in  children.  It  may  be  a  myxoma,  an 
adenoma,  or  a  fibroma,  or  more  often  a  combination  of  various 
histological  elements.  (See  also  Myxoma  in  the  Chapter  on 
Tumors.) 

The  tumors  are  single  or  multiple,  occasionally  disseminated. 
They  are  generally  pedunculated,  and  attached  anywhere  from  just 
within  the  sphincter  to  a  finger-length  higher  in  the  rectum.  They 
vary  in  size  from  that  of  a  pea  to  that  of  a  cherry,  and  are  red  in 
color  unless  protruded  through  the  anus  and  strangulated  by  the 
sphincter. 

Symptoms  and  Diagnosis. — The  symptoms  are  the  urging  to  go 
to  stool,  passing  of  blood  and  sometimes  mucus,  tenesmus,  sometimes 
but  not  always  pain  from  traction  upon  the  pedicle  during  straining. 
The  diagnosis  is  easy  if  the  polypus  protrude  from  the  anus,  and  is 
not  at  all  difficult  if  digital  examination  of  the  rectum  be  made  in 
a  case  presenting  bloody  stools,  fullness  in  the  rectum,  tenesmus, 
fissure  or  prolapse ;  yet  many  a  case  of  polypus  has  been  overlooked. 
The  rectum  should  be  empty  when  examined.  The  polypus  is  often 
so  soft  and  glairy  that  it  eludes  the  finger ;  but  by  passing  the  finger 
laterally  or  spirally  the  pedicle  will  be  caught. 

Treatment. — Spontaneous  cure  sometimes  occurs  by  the  tearing 
loose  of  the  polypus  during  defecation.  One  has  known  this  to  occur 
in  more  than  one  case.  But  it  is  wrong  to  allow  the  child  to  be 
annoyed  or  suffer  from  a  polypus  in  the  rectum  when  it  can  be  re- 
moved so  easily.  Some  advise  merely  seizing  the  pedicle  with  a 
forceps  and  twisting  or  pulling  or  cutting  it  ofif.  But  troublesome 
hemorrhage  may  occur  and  it  is  much  better  and  takes  but  a  short 
time  (the  child  being  placed  under  an  anesthetic  and  the  rectum  di- 
lated) to  pass  a  silk  ligature  about  the  pedicle  close  to  its  base  before 
snipping  it  off.  One  should  be  sure  to  search  for  more  than  one 
growth,  and  remove  all. 

BILHARZIA  ADENOMATA  OF  THE  RECTUM 

This  disease  I  have  never  seen,  but  frequent  communication  with 
the  tropics  may  bring  cases  to  our  country  at  any  time,  or  something 
similar  may  be  found  if  searched  for  in  connection  with  other  va- 


640  SURGICAL   DISEASES    OF   CHILDREN 

rieties  of  flukes  in  our  Southern  States.  D'Arcy  Power  mentions 
a  variety  of  multiple  rectal  adenomata  occurring  in  children  in 
Egypt,  according  to  Dr.  Mackie  of  Alexandria,  as  a  result  of  irri- 
tation produced  by  the  ova  of  the  Bilharzia  hsematobia.  The  tumors 
are  fibro-adenomata  and  are  very  vascular.  The  tissue  of  the  tumors 
contains  an  abundance  of  fertilized  eggs  ready  to  be  hatched  and 
disseminate  the  flukes  by  the  blood  stream. 

Symptoms. — The  symptoms  are  rectal  tenesmus  and  bleeding, 
with  diarrhea.  The  urine  contains  bilharzia  and  is  sometimes  also 
bloody.  The  disease  is  chronic,  and  finally  fatal  by  anemia  and  ex- 
haustion. 

Diagnosis. — Rectal  examination  reveals  the  tumors,  and  when 
the  urine  is  examined  the  diagnosis  is  made. 

Treatment  is  prophylactic.  The  disease  affects  the  blood-vessels 
of  the  whole  genito-urinary  tract  and  local  treatment  is  unavailing. 

PROCTITIS 

Proctitis  or  inflammation  of  the  rectum  may  occur  with  colitis 
or  alone.  It  is  only  when  the  rectum  alone  is  involved  that  the  above 
name  is  applied. 

Etiology. — The  cause  is  usually  local  irritation  or  infection.  A 
common  cause  is  the  use  of  suppositories  of  glycerine  or  of  soap 
for  constipation  in  babies  or  young  children.-  Injections  used  for 
the  same  purpose  are  a  less  frequent  cause,  as  is  also  the  awkward 
use  of  the  syringe.  Proctitis  may  be  caused  by  pinworms.  I  have 
once  seen  a  severe  case  caused  by  the  ill-advised  use  of  a  strong 
solution  of  mercuric  bichloride  for  the  purpose  of  eradicating  pin- 
worms.  Impaction  of  the  rectum  with  hardened  feces  will  some- 
times excite  inflammation,  though  it  is  astonishing  what  a  degree 
of  abuse  the  rectum  will  endure  from  this  cause  without  becoming 
inflamed.  Gonorrhea  or  syphilis  may  appear  in  the  rectum.  Chil- 
dren afflicted  with  various  infections,  particularly  those  infections 
partial  to  mucous  membranes,  as  measles,  scarlet  fever,  and  diph- 
theria, are  prone  to  be  attacked  either  simultaneously  or  subsequently 
with  an  inflammation  of  the  rectum. 

Pathology. — Proctitis  may  be  acute  or  chronic,  and,  varying 
with  the  cause  and  stage  of  the  inflammation,  the  pathologic  condi- 
tion may  present  considerable  differences.  It  may  be  that  of  a 
simple  catarrhal  inflammation,  with  swelling  and  redness  of  the 
mucous  lining,  which  is  hypersensitive,  bleeds  readily  and  secretes 
an  abundance  of  mucus.  Or  in  addition  to  the  symptoms  mentioned 
there  may  be  a  pseudo-membranous  exudation  from  the  inflamed 
base.  Or  ulcers  may  form,  either  follicular  and  multiple,  or  a  single 
ulcer.  Ulceration  may  be  superficial  or  deep  and  irregular  or  regular 
in  shape. 


THE    RECTUM    AND    ANUS  641 

Symptoms  and  Diagnosis. — There  are  usually  frequent  move- 
ments of  the  bowels  ejected  spasmodically,  or  at  least  there  are  at- 
tempts at  defecation  with  a  great  deal  of  tenesmus.  There  is  pain 
in  the  acute  cases  indicated  by  verbal  plaints  in  older  children  or 
crying  and  whining  in  infants.  Several  times  a  day  the  stool  may 
contain  a  considerable  amount  of  fecal  matter,  but  more  frequently 
there  is  only  mucus  or  muco-pus,  often  blood-stained ;  or  if  ulcera- 
tion is  present,  blood  in  larger  or  sometimes  even  quite  large  quan- 
tities in  the  aggregate.  In  the  pseudo-membranous  cases,  by  wash- 
ing the  stools,  fragments  of  the  false  membrane  may  be  found. 
Prolapse  of  the  rectum  may  occur  from  the  frequent  and  violent 
straining.  The  general  condition  suffers.  The  child  becomes  more 
or  less  pale,  emaciated,  and  prostrated.  The  condition  of  the  rectal 
lining  may  be  judged  by  inspection  of  the  exposed  portion  when 
prolapsus  occurs,  or,  better,  by  examination  through  a  speculum. 
It  is  impossible  to  detect  any  ordinary  ulceration  or  form  a  satis- 
factory opinion  upon  the  condition  by  digital  examination  alone. 
The  symptoms  most  nearly  resemble  those  of  colitis  or  ileo-colitis, 
but  at  times  the  stools  are  quite  normal  and  there  is  absence  of  ten- 
derness over  the  colon.  Microscopical  examination  should  be  made 
if  diphtheria  or  gonorrhea  are  suspected.  Probably  very  few  of 
the  cases  presenting  pseudo-membrane  are  really  diphtheritic.  (See 
Section  on  Diphtheria.)  Tuberculous  ulceration  is  very  rare  in 
children. 

Treatment. — A  case  of  any  severity  should  be  kept  in  bed. 
Rest  in  the  horizontal  position  is  a  great  help.  Any  discoverable 
cause  should  be  removed.  In  the  slight  catarrhal  cases  this  is  all 
that  is  required.  Usually  free  irrigation  with  normal  salt  solution  is 
beneficial,  cleansing  the  surface  and  relieving  the  tenesmus.  It  is 
well  to  follow  this  with  an  injection  of  an  ounce  or  a  few  ounces 
of  starch  water,  or  olive  oil  and  lime  water  equal  parts,  or  some- 
times by  creamy  starch  water  in  which  bismuth  subcarbonate  has 
been  suspended,  or  a  dose  of  tincture  of  opium  mixed.  An  attempt 
should  be  made  to  hold  such  an  injection  within  the  rectum  for  a 
time. 

In  the  cases  with  an  excessive  mucous  secretion,  and  in  the 
pseudo-membranous  cases,  solutions  of  boric  acid  are  beneficial, 
if  used  two  or  three  times  a  day.  In  gonorrheal  cases  it  may  be 
needed  many  times  a  day,  and  also  a  solution  of  argyrol,  5  to  10 
per  cent,  applied  with  a  swab  through  a  speculum.  In  gonorrheal, 
in  ulcerative,  and  even  in  some  cases  of  obstinate  chronic  catarrhal 
inflammation,  an  excellent  remedy  is  nitrate  of  silver,  one  grain  to 
the  ounce.  It  is  best  applied  through  a  glass  speculum  after  flush- 
ing out  the  rectum  with  plain  water,  and  following  the  silver  nitrate 
in  a  minute  with  an  irrigation  of  normal  salt  solution.     In  some 


642  SURGICAL   DISEASES    OF   CHILDREN 

cases  two  grains  to  the  ounce  of  silver  nitrate  may  be  used  with  a 
swab,  followed  promptly  by  the  saline  flushing  to  neutralize  the  ex- 
cess. All  cases  of  rectal  ulcer  are  best  treated  with  a  speculum,  at 
least  at  intervals  of  a  few  days,  irrigation  and  the  like  being  em- 
ployed daily.  Through  the  speculum  the  ulcer  may  be  touched  with 
pure  carbolic  acid  or  a  solution  of  silver  nitrate,  ten  or  even  twenty 
grains  to  the  ounce,  or  even  with  the  mitigated  stick.  Any  excess  of 
the  acid  should  be  neutralized  with  alcohol,  and  of  the  silver  salt 
with  sodium  chloride. 

In  all  cases  of  proctitis  the  patient's  diet  should  be  carefully 
regulated,  and  should  be  ample  to  keep  up  his  nutrition  without  un- 
necessary residue. 

SYPHILIS  OF  THE  RECTUM  AND  ANUS 

Lesions  of  hereditary  syphilis  are  seldom  found  within  the 
rectum,  although  gummatous  infiltrations  of  the  intestinal  coats  are 
occasionally  reported.  But  syphilitic  lesions  externally  about  the 
anus  are  comparatively  common.  Erythema  is  doubtless  most  com- 
mon. Cracks  or  fissures  at  the  mucous  margin  of  the  anus  and 
radiating  from  it  into  the  skin  are  common  enough,  and  character- 
istic. Moist  papules  and  confluent  groups  of  these,  or  mucous 
patches,  and  condylomata  are  sometimes  found  in  luetic  subjects. 

Treatment. — Lesions  in  the  rectum  should  be  treated  locally  as 
directed  under  proctitis,  and  also  receive  mercury  and  iodide  of 
potassium.  The  external  manifestations  should  be  treated  by  dusting 
them  with  equal  parts  of  calomel  and  zinc  oxide,  or  touching  the 
patches  with  silver  nitrate.  The  patient  should,  of  course,  also  have 
the  anti-syphilitic  treatment  internally. 


VEGETATIONS    OR   WARTS   ABOUT   THE   ANUS 

These  should  be  mentioned  in  this  connection,  as  they  are  by 
no  means  always  of  syphilitic  origin.  They  may  be  simple  papil- 
lomata  covered  with  squamous  epithelium,  like  warts  upon  any 
other  part  of  the  body.  From  the  moisture  of  this  situation  they 
are  apt  to  grow  rapidly  and  to  swell  to  considerable  size.  If  kept 
dry  and  dusted  with  an  astringent  powder,  such  as  oxide  of  zinc  and 
boric  acid  equal  parts,  or  these  two  with  lycopodium  equal  parts, 
they  shrivel  to  half  the  size  and  may  disappear.  Sometimes  they 
can  be  ligated  and  left  to  drop  off;  or  touched  with  silver  nitrate. 
Or  if  many  and  troublesome  the  galvanic  needle  will  remove  them 
without  hemorrhage ;  or  they  may  be  snipped  off  with  scissors  and 
the  bleeding  stopped  by  touching  with  the  Paquelin  cautery  point. 


THE    RECTUM    AND    ANUS  643 

FISTULA    IN    ANO 

Fistula  in  ano  consists  in  an  abnormal  sinus  or  suppurating" 
track  leading  from  the  rectum  to  the  skin  surface,  in  which  case  it 
is  called  a  complete  fistula ;  or  if  the  track  is  open  only  at  one  end 
and  either  fails  to  communicate  with  the  rectum  or  with  the  external 
surface  it  is  called  an  incomplete  fistula.  Sometimes  the  incom- 
plete varieties  are  spoken  of  as  "  blind  internal  "  or  "  blind  external  " 
fistula,  according  to  the  situation  of  the  opening ;  and  sometimes 
w^e  hear  of  "  horseshoe  fistula,"  etc.,  which  only  draws  attention  to 
the  fact  that  a  fistula  can  be  very  crooked  and  have  more  than  one 
opening  either  outside  or  inside.  Fistula  is  usually  considered  an 
affection  of  adult  life  and  yet  it  is  not  so  very  rare  in  children 
(Allingham,  Wharton),  and  Matthews  records  a  case  in  an  infant 
three  weeks  old  in  which  he  thought  it  congenital. 

Etiology. — The  common  cause  of  fistula  is  abscess,  which  opens 
either  externally  or  internally  or  both.  It  may  take  its  origin  in  a 
wound,  or,  it  is  said,  in  an  ulcer  of  the  rectal  mucous  membrane. 
]\Iatthews  denies  that  it  ever  starts  in  any  other  way  than  in  ab- 
scess. 

Symptoms  and  Diagnosis. — Tenesmus  or  pain  may  possiblv  be 
complained  of,  especially  in  the  "  blind  internal  "  varietv,  which  has 
no  outlet  externally.  But  in  the  complete  or  the  "  blind  external " 
varieties  often  it  is  the  discharge  which  stains  the  clothing  and  leads 
to  examination,  when  the  small  opening  may  be  discovered. 

If  the  probe  be  passed  into  the  external  opening  and  a  finger 
passed  within  the  anus  the  two  may  find  the  internal  opening  if  one 
exists.  If  there  is  no  external  opening  it  may  be  impossible  for  the 
finger  to  find  the  internal  orifice.  But  possibly  a  line  or  a  mass  of 
indurated  tissue  may  be  palpable  either  internally  or  externally  or 
both,  indicating  the  situation  of  the  fistulous  tract.  With  a  speculum, 
pus  may  be  seen  exuding  from  the  internal  orifice,  or  pus  may  be 
found  in  the  stool. 

Treatment. — Treatment  is  the  same  as  in  the  adult.  The  fistula, 
including  all  its  possible  branches  and  pockets,  is  laid  open  from  one 
end  to  the  other  and  allowed  to  heal  from  the  bottom  by  granula- 
tion. To  be  more  explicit:  The  patient  is  prepared  by  thoroughly 
emptying  the  bowels  with  laxatives  on  the  day  before  the  operation 
and  also  on  the  morning  of  the  operation,  early,  and  again  before 
going  to  the  operating  room,  with  enemata.  He  is  anesthetized.  A 
probe,  curved  as  necessary,  followed  by  a  grooved  director,  is  in- 
serted at  the  external  or  the  internal  opening  of  the  fistula,  as  the  case 
may  be.  The  grooved  director  traverses  the  entire  length  of  the 
fistula,  or  as  much  of  it  as  possible,  and  both  ends  of  the  director 
are  brought  out  of  the  anus.    A  knife  is  passed  along  the  groove  of 


644  SURGICAL   DISEASES    OF   CHILDREN 

the  director,  severing  the  tissues.  Careful  search  is  made  with  a 
fine  probe  along  the  track  laid  open,  and  just  beneath  the  margin 
of  the  mucous  end  of  the  cut,  and  again  beneath  the  margin  of  the 
skin  opening,  for  any  branch  sinus  leading  in  any  direction.  All 
sinuses  or  pockets  when  found  are  laid  open  in  the  same  manner. 
The  edges  of  the  skin  orifice  are  trimmed  off,  the  suppurating  track 
of  the  fistula  scraped  out  with  a  sharp  spoon.  The  wound  is  washed 
out  and  packed  with  iodoform  or  cyanide  gauze  and  a  compress  and 
T  bandage  applied.  The  bowels  are  confined  with  opium  for  two 
days,  when  the  first  dressing  is  made.  The  packing  is  thoroughly 
saturated  with  hot  normal  saline  solution  before  its  removal.  The 
bowels  are  moved  by  enema  if  necessary,  the  wound  irrigated  and 
repacked,  and  the  bandage  reapplied.  The  dressings  are  continued 
until  the  wound  granulates  up  from  the  bottom  to  the  surface  and  the 
skin  covers  it. 

FISSURE   OF  THE  ANUS 

Fissure  of  the  anus  is  an  affection  by  no  means  uncommon  in 
children  and  even  in  infants.  (Allingham,  Jacobi,  Curling,  Wharton.) 
I  believe  that  if  more  of  the  children  said  to  be  constipated,  but  who 
really  refuse  to  try  to  defecate,  were  properly  examined,  more  cases 
of  fissure  would  be  discovered  and  a  few  more  of  hemorrhoids. 
The  child  suffers  pain  during  and  more  especially  after  defecation 
and  learns  to  dread  to  go  to  stool.  The  fissure  is  a  small,  narrow, 
linear  ulcer  in  the  mucous  membrane  of  the  anus.  It  is  hidden  at 
the  bottom  of  one  of  the  small  wrinkles  that  radiate  from  the 
opening  and  are  rendered  deeper  by  the  strong  contraction  of  the 
sphincter  that  exists  in  these  cases,  especially  when  one  attempts  an 
examination. 

Symptoms  and  Diagnosis. — The  diagnosis  is  made  from  the  pain 
that  is  experienced  during  defecation  and  especially  for  a  minute  or 
sometimes  quite  a  while  after  defecation,  and  upon  inspection.  The 
pain  is  sometimes  severe,  resembling  that  of  vesical  calculus  upon 
urination,  but  in  other  cases  is  not  so  well  marked  and  only  occasions 
fretfulness  or  slight  crying.  Upon  inspection  the  fissure  is  so  small 
and  concealed  that  it  may  be  overlooked  unless  searched  for.  There 
may  be  slight  bleeding  after  defecation  which,  with  the  pain,  may 
lead  to  a  suspicion  of  rectal  polypus.  Polypus  and  fissure  may  co- 
exist, in  which  case  one  or  the  other  is  apt  to  be  overlooked. 

Treatment. — Divulsion  of  the  sphincter  or  incision  is  scarcely 
ever  necessary  in  fissure  of  the  anus  in  a  child.  But  in  some  children 
it  may  be  necessary  to  give  an  anesthetic  to  make  a  proper  applica- 
tion. The  mucous  membrane  should  be  stretched  so  as  to  expose  the 
fissure,  which  should  be  cleansed  and  then  penciled  with  a  solution 
of  silver  nitrate,  twenty  grains  to  the  ounce,  or  the  solid  stick  of  silver 
nitrate,  and  then  well  smeared  with  an  ointment  of  iodoform  in 


THE  RECTUM  AND  ANUS  645 

vaseline,  or,  if  the  odor  is  objectionable,  with  boracic  ointment  or 
zinc  ointment,  which  are  not  as  good.  The  parts  should  be  kept 
well  coated  with  the  ointment  for  several  days,  and  the  diet  and 
bowels  regulated. 

HEMORRHOIDS 
Hemmorrhoids  are  very  uncommon  in  children,  yet  cases  of 
both  the  internal  and  external  varieties  have  been  reported.  One 
has  met  them  a  number  of  times,  the  external  being  more  usual. 
They  are  invariably  accompanied  by  and  apparently  the  result  of 
chronic  constipation.  The  symptoms  are  the  same  but  less  pro- 
nounced than  in  the  adult.  Treatment  is  directed  toward  the  cure 
of  constipation.  Locally,  during  the  hemorrhoidal  attack,  the  appli- 
cation of  hot  water,  especially  if  it  be  directed  against  the  piles  in  a 
jet  from  a  fountain  syringe,  greatly  relieves  the  pain  and  soreness. 
Lead  and  opium  wash  may  be  applied  hot  on  a  gauze  compress. 
Suppositories  containing  belladonna  and  one-fourth  to  one  grain 
of  cocaine  are  useful.  The  rectum  should  be  kept  empty.  Just  be- 
fore each  defecation  half  a  pint  or  a  pint  of  flaxseed  tea,  which  is 
like  thin  mucilage,  with  common  salt  a  drachm  to  the  pint,  should 
be  injected.  This  protects  and  lubricates  the  mucous  membrane 
and  causes  an  easy  passage.  This  simple  line  of  treatment  I  have 
found  very  satisfactory,  relieving  the  trouble  promptly.  While 
adults  seldom  recover  permanently  without  operation,  children 
usually  do. 

ISCHIO-RECTAL  ABSCESS 

Ischio-rectal  abscess  is  an  inflammation  with  pus  formation  in 
the  cellular  tissues  in  the  neighborhood  of  the  rectum.  It  results 
from  injury,  such  as  a  fall  or  a  blow  or  a  punctured  wound, 
perhaps  even  from  the  pressure  of  fecal  masses  in  the  rectum  or 
from  straining  at  stool.  Perforating  ulceration  of  the  rectum  is  set 
down  as  a  cause,  which  must  be  a  rare  one,  deep  ulceration  of  the 
rectum  being  unusual  in  children.  But  an  ulcer  may  serve  as  an  in- 
fection atrium.  No  doubt  many  cases,  probably  the  majority,  have 
their  origin  in  infection  through  the  lymph  channels  in  connection 
with  the  mucous  lining  of  the  rectum,  without  demonstrable  ulcera- 
tion. Foreign  body,  may,  in  rare  cases,  act  as  a  cause.  The 
symptoms  are  tenderness,  pain,  swelling,  fever,  local  redness.  The 
tenderness  and  pain  are  quite  severe.  The  swelling  may,  after  some 
days,  be  evident  externally  and  become  quite  tense  and  brawny, 
and,  if  allowed  to  go  on,  may  fluctuate  and  finally  open ;  or  it  may 
not  be  prominent  externally,  but  bulge  within  the  rectum.  There 
is  not  so  much  of  a  tendency  in  children  as  in  adults  for  ischio- 
rectal abscess  to  become  chronic  or  to  cause  fistula,  yet  occasionally 
fistula  results.     (See  Section  on  Fistula  in  Ano.) 


646  SURGICAL  DISEASES  OF  CHILDREN 

Treatment. — As  soon  as  abscess  can  be  demonstrated  it  should 
be  opened  by  incision.  An  anesthetic  should  be  used,  as  the  inflamed 
parts  are  extremely  sensitive,  and  the  opening  should  be  made  care- 
fully and  thoroughly,  and  not  hurriedly.  Unless  one  waits  until 
the  abscess  is  approaching  the  surface,  which  he  should  not  do,  as  it 
entails  needless  suffering  and  breaking  down  of  tissue,  and  may  cause 
fistula,  it  may  be  necessary  to  find  the  abscess  at  a  little  depth. 
The  usual  direction  given  is  to  thrust  in  the  knife  and  make  the 
incision  in  a  direction  radiating  from  the  outer  margin  of  the 
sphincter,  or  to  make  a  crucial  incision.  Matthews  insists  on  having 
the  incision  parallel  with  the  sphincter,  so  that  contraction  of  the 
sphincter  tends  to  keep  the  wound  open.  The  essential  points  are : 
Free  opening  of  abscess  and  all  loculi,  washing  out  with  hot  bichlo- 
ride solution,  I  to  2000,  packing  with  iodoform  or  cyanide  gauze,  an 
outside  antiseptic  pad ;  after  two  days,  reirrigation  and  packing,  and 
so  on  until  healed  by  granulation  from  the  bottom. 

MARGINAL  ABSCESS 

Marginal  abscess  is  a  circumscribed  inflammation  at  the  margin 
of  the  anus.  It  starts  from  infection  of  an  abrasion  or  excoriation 
or  fissure,  or  from  a  mucous  follicle.  It  never  exteads  deeply  and 
when  lanced  and  dressed  with  carbolized  vaseline  it  soon  heals. 

FOREIGN  BODIES  AND  IMPACTIONS 

Foreign  bodies  may  be  accidentally  or  mischievously  introduced 
into  the  rectum  per  anum,  or,  descending  from  the  bowel,  may  lodge 
there.  They  may  or  may  not  be  embedded  in  faecal  matter.  Prune 
stones  and  other  seeds,  meat  bones,  fish  bones,  coins,  buttons,  irregu- 
lar shaped  articles,  or  enteroliths  may  be  found.  The  symptoms 
are  pain,  tenesmus,  sometimes  bloody  discharge,  not  always  consti- 
pation. They  may  be  readily  removed  by  finger  or  forceps  or  spoon 
handle ;  or  may  require  anesthesia  and  the  use  of  specula  and  other 
instruments  or  even  a  posterior  proctotomy  for  their  removal. 
INEFFICIENCY  OF  THE  SPHINCTER  ANI 

Idiotic  children  and  imbeciles  may  fail  to  control  their  de- 
jections. These  cases  are  in  a  class  by  themselves.  There  is  no 
permanent  help  for  them  other  than  general  management  and  train- 
ing. Or  the  cause  of  the  fsecal  incontinence  may  lie  in  some  otlier 
form  of  nervous  disorder,  as  in  spina  bifida,  injury  to  the  lumbar 
spine,  myelitis,  and  meningitis ;  in  the  extreme  general  relaxation 
which  follows  any  exhausting  disease ;  or  in  local  over-strain 
such  as  comes  from  tenesmus  with  repeated  rectal  prolapse,  the  pro- 
tusion  of  a  tumor,  or  the  like.  Or  it  may  result  from  accidental  in- 
jury to  the  sphincter,  or  from  a  surgical  operation.  Obviously  the 
prognosis  and  treatment  must  vary  with  the  cause. 


CHAPTER   XXIV 

THE    GENITO-URINARY    ORGANS 

The  Kidneys;  Normal  Anatomy,  and  Malformations — Float- 
ing Kidney — Injuries  of  the  Kidney — Perinephritis  and 
Pyo-Perinephritis  —  Hydronephrosis  and  Hydroperine- 
phrosis — Renal  Calculus — Tubercular  Nephritis — Tu- 
mors of  the  Kidney — Extroversion  of  the  Bladder  (Ecto- 
pia Vesicae) — Tumors  of  the  Bladder — Stone  in  the 
Bladder — Calculus  in  the  Urethra_,  Foreign  Body  in  the 
Urethra  or  in  the  Bladder — Rupture  of  the  Urethra — 
Epispadias — Hypospadias — Adherent  Prepuce — Phimosis — 
Paraphimosis — Other  Constrictions  of  the  Penis — Dis- 
location OF  THE  Penis — Balanitis — Urethritis — Unde- 
scended Testis,  and  Misplaced  and  Hidden  Testis — Super- 
numerary Testis — Tumors  of  the  Testis — Orchitis — Tor- 
sion OF  THE  Spermatic  Cord — Varicocele — Tuberculosis 
OF  the  Testicle  and  of  the  Epididymis — Syphilitic  Testi- 
tis — Hydrocele  in  the  Male — Cyst  of  the  Spermatic  Cord 
— Misplacement  of  Ovaries — Ovarian  Tumors — Adhe- 
sion of  the  Labia  Minora — Adhesion  of  the  Clitoris 
and  Its  Prepuce — Prolapse  of  tfie  Female  Urethra — 
Vulvitis — Vulvo-Vaginitis,    Simple   and    Specific. 

THE  KIDNEYS;  NORMAL  ANATOMY,  AND  MALFORMATIONS 

The  situation  of  the  kidneys  in  the  new-born  is  from  the  level 
of  the  disc  between  the  twelfth  dorsal  and  first  lumbar  vertebrae  to 
that  between  the  third  and  fourth  lumbar  vertebrae.  It  is  generally 
stated  that  the  left  kidney  is  longer  than  the  right,  and  that  the  right 
is  placed  at  a  lower  level  than  the  left,  presumably  on  account  of 
the  large  amount  of  room  needed  by  the  liver  upon  the  right  side. 
But  Ballantyne  does  not  find  this  true  in  the  infant,  neither  as  re- 
gards the  size  nor  the  position.  PTe  finds  the  right  kidney  measur- 
ing about  3.8  centimetres  vertically  and  the  left  about  3.5  centimetres. 
The  greatest  antero-posterior  diameter  is  from  1.5  to  1.8  centi- 
metres, and  the  greatest  transverse  about  2.;^  centimetres.  Thus 
the  right  and  not  the  left  is  the  longer.  The  position  on  the  two 
sides  is  the  same.  The  hilus  corresponds  to  the  level  of  the  second 
lumbar  vertebra,  and  the  lower  end  of  each  kidney  is  only  a  few 
millimetres  from  the  crest  of  the  ilium. 

647 


648  SURGICAL  DISEASES   OF   CHILDREN 

The  suprarenal  capsule  is  large  in  infancy,  being  about  one- 
third  the  size  of  the  kidney,  upon  the  upper  end  of  which  it  rests 
like  a  pyramidal  cap.  It  covers  more  of  the  kidney  in  front  than 
behind. 

The  muscular  walls  covering  the  kidneys  postero-laterally  are 
but  thin  and  poorly  developed  in  the  infant  and  young  child  and 
afford  but  slight  protection  from  a  blow  or  a  crushing  force.  The 
kidneys  are  more  lobulated  than  in  older  persons,  but  not  so  much  so 
as  in  the  fetal  state.  In  some  instances  exaggerated  lobulation,  re- 
sembling that  of  the  fetal  state  or  even  more  distinctly  marked,  ex- 
ists as  a  malformation.  Again,  there  is  absence  of  one  kidney,  or 
it  is  diminutive,  while  the  other  one  is  of  extra  size  and  probably 
of  unsymmetrical  shape.  In  some  cases  single  kidney  has  been 
associated  with  malformation  of  some  part  of  the  generative  organs. 
Another  malformation  is  known  as  the  horseshoe  kidney.  In  this 
either  the  upper  or  lower  ends  of  the  kidneys  are  connected  together 
by  a  continuation  of  kidney  tissue,  so  that  the  whole  organ, 
composed  of  both  kidneys  and  the  bridge  between  them,  takes  a 
shape  resembling  a  horseshoe.  Other  forms  of  fusion  may  occur. 
The  kidneys  are  sometimes  found  fixed  in  anomalous  positions;  or 
loose  in  their  normal  attachments  and  more  or  less  movable  from 
the  normal  position.  Kidneys  that  are  abnormal  in  shape  are  more 
likely  to  become  diseased;  and  are  also  more  likely  to  be  found  in 
an  abnormal  position. 

FLOATING  KIDNEY 

Floating  kidney  is  an  affection  not  at  all  common  in  children. 
Yet  now  and  again  cases  are  reported.  When  found  in  children  it 
has  been  more  frequent  in  older  girls  approaching  adolescence,  and 
the  right  kidney  rather  than  the  left.  If  the  cause  is  congenitally 
lengthened  peritoneal  attachments  of  the  kidney,  real  meso-nephron, 
as  some  aver,  it  would  seem  there  ought  to  be  more  cases  discovered 
in  childhood.  Among  the  other  causes  of  movable  kidney  are 
mentioned  tight  lacing,  relaxed  abdominal  walls  following  pregnancy 
or  from  debility,  emaciation  removing  the  adipose  "  packing  "  about 
the  kidney,  increased  vascularity  during  the  menstrual  period, 
violent  descent  of  the  diaphragm  as  in  vomiting,  violent  physical 
exertion,  and  asthmatic  attacks,  none  of  which,  excepting  physical 
exertion  and  vomiting,  pertain  to  childhood. 

Symptoms  and  Diagnosis. — The  symptoms  are  of  several  groups, 
local,  psychic  and  reflex,  and  referable  to  the  function  of  the  kidneys. 
Among  the  local  symptoms  are  pain  and  feeling  of  weight,  burning 
and  tearing  sensations,  referred  to  the  lumbar  region,  or  sometimes 
to  the  loin,  groin,  and  thigh.  Among  the  psychic,  hypochondria ; 
while  the  reflex  often  takes  the  form  of  digestive  disorder.     Kidney 


THE    GENITO-URINARY    ORGANS  649 

function  often  shows  disturbance  by  suppression  of  urine,  hematuria 
or  albuminuria.  Physical  examination  may  reveal  that  the  kidney 
is  absent  from  its  normal  situation ;  and  with  the  patient  lying  on 
the  back,  thighs  flexed  and  abdominal  muscles  relaxed,  with  one 
hand  of  the  examiner  behind  the  kidney  and  one  in  front,  the  kidney 
may  be  palpated,  and  may  be  felt  to  make  an  excursion  upward  and 
downward  with  each  respiratory  act.  In  some  cases  it  can  be  lifted 
from  its  bed  and  moved  about  or  restored  to  its  normal  situation 
when  displaced. 

Not  every  kidney  which  can  be  moved  should  be  called  a  float- 
ing kidney,  but  only  such  as  can  be  freely  moved  about.  If  there 
is  difficulty  in  distinguishing  between  spleen  and  left  kidney  it  is 
well  to  remember  not  only  that  the  spleen  has  its  notch  but  that  the 
colon  lies  between  the  two  organs,  and  by  distending  it  with  air  the 
tympanitic  area  between  spleen  and  kidney  can  be  demonstrated. 
In  the  adult  a  distended  gall-bladder  and  the  kidney  may  be  con- 
founded, but  in  the  child  enlargement  of  the  gall-bladder  to  such 
an  extent  may  be  ruled  out.  There  may  be  hydated  cyst  connected 
with  the  liver  even  in  a  young  child. 

Treatment. — The  kidney  should  be  replaced  and  supported  in 
its  normal  position  by  a  broad  bandage  furnished  with  a  pad  to 
make  pressure  upon  the  proper  spot  in  front  of  the  abdomen.  If 
hematuria  or  albuminuria  or  suppression  of  urine  supervene,  the 
patient  should  be  confined  to  bed,  and  a  good  part  of  the  time  in 
the  dorsal  decubitus,  till  the  symptoms  pass  off.  If  notwithstanding 
these  palliative  measures  the  symptoms  are  too  troublesome,  the 
operation  of  nephropexy  must  be  resorted  to. 

INJURIES  OF  THE  KIDNEY 

Owing  to  the  thinness  of  the  muscles  and  ribs  covering  it,  and 
the  lack  of  fat  surrounding  it,  also  to  the  frailness  of  the  whole 
body  of  the  child,  the  kidney  is  very  easily  injured  by  a  blow  or  kick 
or  by  the  passage  of  a  carriage  wheel,  or  by  a  fall,  or  by  similar 
violence. 

Pathology. — Contusions  and  crushes  form  by  far  the  greatest 
number  of  injuries  to  the  kidney.  These  may  vary  greatly  in  de- 
gree and  extent,  from  a  slight  bruising  to  a  pulpifying  of  a  part  or 
the  whole  of  a  kidney,  or  a  laceration,  or  a  bursting  of  the  organ 
by  pressure.  The  outer  or  the  inner  portion  of  the  viscus  may  suf- 
fer most  so  that  hemorrhage  may  take  place  beneath  the  capsule, 
or,  if  that  is  lacerated,  the  blood  may  collect  in  the  cellular  tissue  sur- 
rounding the  kidney.  Or  hemorrhage  may  take  place  only  within 
the  pelvis  of  the  organ,  or  both  blood  and  urine  may  escape  into 
perirenal  tissue. 


650  SURGICAL   DISEASES    OF   CHILDREN 

The  more  remote  results  of  contusions  and  crushes  of  the  kid- 
ney are :  nephritis,  perhaps  going  on  to  abscess ;  pyonephrosis,  peri- 
nephritis, pyo-perinephritis  or  perinephric  abscess,  hydro-nephrosis, 
hydro-perinephrosis. 

Symptoms  and  Course. — Following  an  injury  at  all  serious  to 
the  kidney,  there  is  shock,  but  less  than  after  injury  of  other  internal 
organs ;  pain  which  may  be  referred  to  either  the  renal  region  or 
to  the  abdomen,  testicle,  or  even  to  the  thigh.  Inspection  may  reveal 
a  local  mark,  bruise  or  other  external  evidence  of  injury ;  but  serious 
injury  may  be  inflicted  upon  the  kidney  without  leaving  any  external 
trace.  There  may  be  local  tenderness  or  this  may  not  appear  until 
resulting  inflammation  has  supervened,  when  there  will  be  also  fever, 
tension,  increased  pain,  perhaps  edema  in  the  renal  region,  and 
distension  of  the  abdomen.  Hematuria  following  violence  inflicted 
upon  the  kidney  region  neither  proves  nor  disproves  serious  injury 
to  that  organ.  Severe  bruising,  laceration  or  even  rupture  of  the 
kidney  may  occur  without  causing  bloody  urine.  The  hemorrhage 
may  take  place  outside  the  kidney.  Or,  if  hemorrhage  takes  place 
into  the  pelvis  of  the  kidney,  the  clotting  of  the  blood  may  plug  the 
ureter  and  so  prevent  the  passage  of  bloody  urine. 

Hematuria  after  injury  may  appear  at  once,  or  not  until  after 
several  days,  or  be  continuous  or  intermittent  as  clot  in  the  pelvis 
allows  it  to  pass,  or  as  clots  make  their  escape  through  the  ureter, 
with  pain  like  the  passage  of  renal  calculus.  Or  clot  may  plug  the 
urethra  at  the  neck  of  the  bladder  and  so  prevent  the  passage  of 
bloody  urine  or  cause  it  to  be  passed  spasmodically  or  intermittently 
with  frequent  urgent  attempts  and  pains  like  those  of  vesical  calcu- 
lus. Simple  congestion  of  the  kidney  from  a  jar  or  slight  bruise 
may  give  rise  to  hematuria  without  any  visible  solution  of  continuity. 

Penetrating  and  incised  wounds,  while  less  frequent  than  con- 
tusions or  crushes,  are  occasionally  met  with,  and  give  rise  to  symp- 
toms similar  to  those  previously  described,  to  which  may  be  added 
external  hemorrhage  and  discharge  of  urine  in  some  cases.  But 
external  hemorrhage  is  not  invariable,  nor  does  the  absence  of 
urine  from  the  discharges  of  the  wound  make  it  certain  that  the  kid- 
ney has  not  been  injured.  Hemorrhage  is  usually  more  severe  in 
incised  or  stab  wounds  than  in  lacerations,  but  it  may  be  concealed 
internally,  and  the  probability  of  the  peritoneum  having  been  injured 
should  always  be  thought  of.  The  kidney,  either  injured  or  unin- 
jured in  its  substance,  may  be  torn  from  its^bed,  or  even  in  extensive 
laceration  of  the  loin  made  to  protrude  through  the  parietes. 

Diagnosis. — The  diagnosis  is  made  upon  the  following  train  of 
symptoms :  A  child  receives  some  violence  in  the  lumbar  region  or 
has  a  fall  by  which  the  body  is  severely  bent.  There  is  shock  fol- 
lowed by  pain  and  perhaps  vomiting.    Soon,  or  in  a  day  or  two  after 


THE    GENITO-URINARY    ORGANS  651 

the  accident,  there  is  bloody  urine  which  gradually  diminishes  or 
is  intermittent  for  several  days  or  a  week.  In  such  a  case  the  pre- 
sumption is  strong  that  a  moderate  contusion  or  even  a  laceration 
of  the  kidney  had  taken  place.  But  if  in  addition  to  these  symptoms 
extreme  tenderness  and  a  dull  tumefaction  appear  in  the  renal 
region  and  over  that  side  of  the  abdomen  with  fixation  of  the  ad- 
jacent muscles,  with  pain  and  retraction  of  the  testicle  or  agony  in 
the  groin,  with  frequent  desire  to  micturate  and  a  hard  pulse  and 
rising  fever,  one  would  make  a  diagnosis  of  a  ruptured  kidnev. 

Symptoms  of  injury  to  the  kidney  may  be  strangely  delayed 
even  for  days  in  their  appearance ;  and  after  a  history  of  injury  in 
this  region,  with  or  without  the  appearance  of  any  of  the  symptoms 
of  injury,  one  should  be  very  cautious  about  dismissing  the  case  as 
sound.  Not  merely  days  but  weeks  may  elapse  before  symptoms  of 
hydro-nephrosis,  or  other  result,  may  manifest  itself.  In  cases  ac- 
companied by  external  wound  the  diagnosis  may  be  easier  judging 
from  the  extent  and  direction  of  the  wound. 

Prognosis. — The  kidney  is  tolerant  of  moderate  injury,  and  re- 
covery not  only  of  the  patient  but  of  the  usefulness  of  the  organ 
is  expected  in  slight  contusions  and  even  in  lacerations.  Injury  to 
the  cortex  of  the  kidney  may  occasion  sharp  but  not  necessarily 
dangerous  hemorrhage,  but  wound  into  the  renal  artery  or  vein 
leads  to  furious  hemorrhage.  The  prognosis  often  turns  upon  the 
point  whether  the  peritoneum  as  well  as  the  kidney  is  sufficiently 
injured  to  become  inflamed.  And  much  depends  upon  the  treatment ; 
whether,  for  instance,  in  case  of  extensive  injury  the  loin  is  incised 
and  the  hemorrhage  controlled,  or  whether,  abscess  forming,  it  is 
relieved  by  lumbar  incision  and  drainage. 

Punctured  and  incised  wounds  present  their  usual  dangers,  both 
of  hemorrhage,  either  external  or  concealed,  and  of  infection;  but 
they  are  not  on  the  whole  more  serious  than  injuries  of  the  kidne}- 
without  external  wound.  The  external  wound  may  even  be  turned 
to  advantage  as  a  drain,  and  renal  fistula  is  not  likely  to  persist. 

Treatment. — In  the  treatment  of  injuries  of  the  kidney,  stim- 
ulants should  be  carefully  avoided  and  absolute  rest  in  bed  en- 
joined. The  side  or  the  side  and  abdomen  should  be  strapped 
or  bandaged,  laxatives  avoided,  and  vomiting,  if  present,  controlled, 
and  no  bulky  food  allowed.  The  strapping  promotes  rest,  and  also 
tends  to  control  hemorrhage  by  pressure.  Even  several  days  after 
the  injury  hemorrhage  may  supervene,  or,  having  been  checked, 
may  return  by  moving,  coughing,  straining  at  stool  or  the  like. 
Pain  also  is  relieved  by  the  strapping  and  rest,  but  anodynes,  too, 
may  be  needed.  In  hematuria  or  suspected  internal  hemorrhage, 
ergot  or  gallic  acid  are  advised.  If  extensive  internal  hemorrhage 
or  extravasation  of  urine  are  evident,  nothing  will  avail  but  lumbar 


652  SURGICAL   DISEASES    OF   CHILDREN 

incision  to  evacuate  the  fluids,  and,  if  necessary,  control  th.e  hemor- 
rhage. Hemorrhage  from  the  substance  of  the  kidney  can  gen- 
erally be  controlled  by  pressure  or  packing,  but  clamp  or  ligatures 
are  necessary  for  the  renal  vessels.  Nephrectomy  should  not  be 
thought  of  at  this  time  unless  hemorrhage  is  otherwise  uncon- 
trollable, but  the  kidney  should  be  given  a  chance  to  recover  its 
usefulness. 

PERINEPHRITIS  AND  PYO-PERINEPHRITIS 

An  inflammation  of  the  cellular  and  adipose  tissues  envelop- 
ing the  kidney  is  called  perinephritis.  If  the  inflammation  goes 
on  to  suppuration  we  have  a  condition  which  may  be  named  pyo- 
perinephritis.  It  has  usually  been  described  under  the  term  peri- 
nephric abscess. 

Pathology. — The  inflammation  may  involve  only  a  small  or  a 
large  area.  It  may  involve  the  perinephric  tissues  alone,  or  the 
kidney  also.  There  may  be  several  small  abscesses  or  a  larger  one, 
and  there  may  or  may  not  be  any  opening  between  the  pelvis  of 
the  kidney  and  the  abscess  cavity  outside  the  kidney. 

Causation. — Perinephritis  and  pyo-perinephritis  may  be  trau- 
matic or  idiopathic  in  origin.  They  may  originate  outside  of  the 
kidney,  or  within  the  organ  and  then  extend  outward.  Calculus 
is  a  very  common  cause  of  the  disease  when  beginning  within  the 
kidney.  Spinal  caries  is  an  example  of  another  very  common 
cause  lying  outside  of  the  organ.  Empyema  burrowing  downward, 
appendicitis  extending  upward,  may  excite  a  perinephritis.  Inflam- 
mation from  either  traumatic  or  other  pathologic  cause  may  extend 
from  bladder,  ureter,  testicle,  spermatic  cord,  anal  region,  or  rec- 
tum. Tubercle,  sarcoma,  carcinoma,  cyst,  hydatids,  nephritis,  or 
pyelo-nephritis  from  whatever  cause  may  give  rise  to  an  inflam- 
mation resulting  in  suppuration  in  perinephric  tissues.  The  effects 
of  phimosis  and  congenital  narrowing  of  the  meatus  urinarius  have 
been  followed  by  disease  of  the  kidney  extending  outside  of  it. 
Cold  or  exposure,  various  local  injuries,  as  blows  and  wounds, 
besides  falls  and  jars,  have  all  been  charged  with  producing  peri- 
nephritis and  pyo-perinephritis.  In  some  cases  no  known  exciting 
cause  could  be  adduced,  but  the  patient  was  said  to  be  "  run  down  " 
or  "  subject  to  abscesses." 

Symptoms  and  Diagnosis. — The  symptoms  are  by  no  means 
uniform,  and  especially  in  the  secondary,  cases  may  be  insidious, 
or  masked  by  the  primary  disease.  Other  cases  are  very  frank, 
with  a  prompt  onset;  fever  102°,  103°,  104°  F. ;  local  pain,  stiffness 
of  muscles  in  the  lumbar  region,  and,  when  suppuration  sets  in, 
chills  or  chilliness,  fluctuating  temperature,  and  perhaps  tender- 
ness, tumor,  fullness  or  heaviness  in  the  loin. 


THE    GENITO-URINARY    ORGANS  653 

In  children,  fever  is  a  very  uncertain  indication  of  the  severity 
of  a  disease ;  and  a  large  abscess  may  form  with  very  little  rise  of 
temperature ;  and  fever  tells  us  nothing  of  the  location  of  the  trou- 
ble. Pain  may  be  distinctly  located  in  the  loin.  But  children  often 
do  not  locate  pain  accurately,  or  with  them,  as  with  the  adult,  there 
may  be  pain  with  any  movement  of  the  trunk,  or  the  pain  may 
be  felt  in  the  knee,  thigh,  or  gentalia,  groin  or  abdomen.  In  cases 
secondary  to  renal  disease  the  urine  may  give  valuable  indications 
— pus,  blood,  albumen,  or  casts.  In  primary  perinephritis  the  urine 
may  show  nothing  abnormal,  or  it  may  be  excessively  acid  or 
loaded  with  lithates,  or  may  contain  albumen  merely  from  pressure 
of  the  swelling  on  the  renal  vein.  Tenderness  in  the  region  of  the 
kidney  may  be  easily  demonstrated  or  may  require  quite  deep  pres- 
sure. Or  the  parts  may  be  sensitive  to  slight  touch,  and  firm 
pressure  cause  such  sharp  pain,  sticking  and  aching  as  to  be  un- 
bearable. If  there  is  much  swelling  or  a  large  accumulation  of  pus, 
tumor  is  generally  demonstrable,  at  least  under  an  anesthetic.  But 
sometimes  there  is  more  of  a  feeling  of  immobility,  or  of  weight 
on  the  affected  side,  when  both  sides  are  tested  by  lifting,  as  it 
were,  one  loin  in  each  hand  as  the  patient  lies  upon  the  back.  Ex- 
ternal edema  and  even  redness  of  the  skin  may  be  met,  but  a  diag- 
nosis ought  to  be  made  before  that  appears. 

All  of  these  symptoms  are  more  or  less  fallacious,  and  may  be 
difficult  to  find  or  to  judge  in  children ;  which  makes  it  necessary 
to  look  very  closely  for  more  reliable  symptoms,  muscular  rigidity, 
and  the  characteristic  attitude  and  movements  of  the  young  patient. 
The  lumbar  spine  is  stiff,  and  when  the  patient  is  recumbent  is 
curved  slightly  forward.  With  the  patient  standing  the  effort  to 
erect  the  dorsal  spine  causes  a  lordosis.  Or,  in  standing,  the  patient 
may  support  the  spine  by  resting  the  hand  upon  the  thigh.  Tor- 
sion of  the  spine,  as  in  turning  in  bed,  is  impossible  or  causes 
great  pain.  Rather  than  stoop  or  bend,  the  patient  will  squat. 
Sometimes  the  body  is  much  inclined  toward  the  affected  side.  The 
thigh  is  partially  fixed  upon  the  trunk  when  either  lying,  sitting, 
or  standing.  While  lying  on  the  back  the  patient  cannot  extend 
the  thigh  to  touch  the  bed  or  table,  nor  can  the  thigh  be  com- 
pletely extended  by  passive  motion.  Adduction  and  abduction  are 
possible  and  the  foot  is  usually  pointed  forward ;  but  occasionally 
there  is  outward  rotation. 

In  standing,  the  thigh  flexion  persists  and  causes  a  limp  in 
walking,  and  he  may  walk,  supporting  the  body  by  resting  the  hand 
upon  the  thigh.  The  patient  can  even  stand  on  the  limb  of  the 
affected  side  by  leaning  far  over,  thus  maintaining  the  flexion  of 
the  thigh. 

Pain  may  be  caused  by  adduction  or  by  jarring.     In  any  case 


6S4  SURGICAL   DISEASES    OF   CHILDREN 

of  suspected  perinephritis  the  bowels  should  be  thoroughly  emptied 
before  diagnosis  is  attempted.  Fecal  impaction  and  consequent 
pain  may  simulate  this  disease,  and  all  disappear  by  appropriate 
use  of  enemata  and  laxatives.  The  disease  must  also  be  differen- 
tiated from  hip-disease,  spinal  caries,  gravel,  lumbago,  appendicitis, 
splenitis,  hepatitis,  and  empyema. 

Prognosis. — Prognosis  depends  on  the  cause  and  the  severity 
of  the  attack,  and  in  case  of  pyo-perinephritis  it  also  depends  on  the 
stage  at  which  the  abscess  is  freely  opened.  Necessarily  an  in- 
flammation so  deeply  seated  and  so  surrounded  with  important 
structures  is  a  serious  affair.  And  yet  slight  cases  of  primary 
perinephritis  may  subside  without  suppuration  and  leave  no  trace. 
The  dangers  are  from  destruction  of  the  kidney,  hectic,  pyemia, 
peritonitis  from  extension  to  or  bursting  into  the  peritoneum,  bur- 
rowing of  pus  over  into  the  other  loin,  or  downward  along  the  psoas, 
or  upward  into  the  pleura  or  lung,  or  under  the  Hver,  or  into  the 
colon  or  ureter.  The  effects  of  treatment  are  rather  more  satis- 
factory in  the  child  than  in  the  adult. 

Treatment. — A  prompt  and  thorough  laxative  is  not  only 
requisite  to  a  careful  examination,  but  is  an  excellent  therapeutic 
measure.  The  bowels  should  be  kept  moderately  active.  No  bulky 
or  heavy  food  should  be  allowed.  Milk,  or  rather,  fluid  diet,  is 
advised.  The  arterial  tension,  fever  and  restlessness  of  the  early 
stage  may  be  controlled  by  aconite  or  moderate  doses  of  acetanilid. 
These  remedies  also  act  well  upon  the  skin,  and  thus  relieve  the 
kidneys.  They  may  be  supplemented  by  sudorifics,  such  as  spirit 
of  Minderer. 

Pain  should  be  relieved  by  anodynes,  morphia,  or,  preferably, 
codeine.  A  good  extract  of  belladonna,  one  drachm  to  an  ounce 
of  glycerine,  smeared  upon  the  painful  region  after  carefully 
cleansing  the  skin,  and  then  protected  by  oil-silk,  aids  in  relieving 
the  pain,  and  perhaps  influences  the  local  circulation  beneficially. 
Guiacol  in  oil,  or  ointment  containing  iodide  of  lead,  are  sometimes 
applied. 

Any  of  these  applications  may  be  covered  by  a  hot-water  bag; 
or  hot  fomentations,  stupes  or  poultices  may  be  used,  with  or  with- 
out any  other  application.  These  means  or  blistering  may  promote 
resolution  in  such  cases  as  do  not  go  on  to  suppuration.  Some 
surgeons  prefer  cold  applications,  and  in  some  cases  these  prove 
more  grateful  to  the  patient  and  limit  the  congestion  better  than 
local  heat.  Hot  baths  or  sitz  baths  are  also  useful.  Leeching  was 
formerly  much  used,  and  should  be  thought  of  in  plethoric  cases. 
So  also  wet  cupping.  Dry  cupping  has  a  wider  range  of  applica- 
tion and  is  more  readily  consented  to  by  the  patient  or  parents. 
If  pus  forms  there  is  nothing  for  it  but  removal,  and  the  sooner 


THE    GENITO-URINARY    ORGANS  655 

the  better.  Aspiration  may  serve  temporarily  for  removal  of  the 
pus,  particularly  in  chronic  or  slow  cases,  but  incision  is  the  sov- 
ereign remedy.  The  aspirating  needle  may  be  used  as  a  guide  to 
the  point  for  incision.  However,  that  is  usually  settled  upon  ana- 
tomical grounds,  in  cases  in  which  tumor  or  fluctuation  offer  no 
indication.  Fluctuation,  edema  and  redness  of  the  skin — in  other 
words,  "  pointing  "  of  the  abscess — should  not  be  waited  for.  The 
general  symptoms  indicative  of  pus  formation,  together  with  the 
fullness  or  bulging,  local  pain  or  aching,  hardness  or  weight,  with 
dullness  on  percussion  extending  in  a  region  that  should  be  reso- 
nant— are  sufficient  to  call  for  incision.  The  incision  is  the  same  as 
for  nephrotomy  and  may  be  either  transverse,  oblique,  or  vertical. 
My  own  preference  is  for  the  oblique  incision,  parallel  with  the 
twelfth  rib.  After  the  skin  and  muscles  are  cut  through,  a  blunt 
instrument,  or  preferably  the  finger,  seeks  the  abscess.  Flocculi 
or  sloughs  should  be  removed  and  a  drainage  tube,  or  perhaps 
two  of  them  side  by  side,  should  be  introduced.  It  is  not  necessary 
to  irrigate  the  cavity  at  the  time  of  operation  in  every  case.  It 
may  be  omitted  unless  the  pus  is  foul.  Later,  washings  with  nor- 
mal salt,  boracic,  weak  bichloride  or  other  lotion  may  be  necessary. 
The  wound  is  packed  with  iodoform  gauze  and  surrounded  with 
abundance  of  sterile  or  cyanide  gauze  or  pads  of  sublimated  or 
tarred  jute  or  absorbent  cotton. 

No  fear  should  be  entertained  of  a  permanent  fistula,  but  the 
external  opening  maintained  until  the  whole  cavity  has  closed  by 
granulation. 

HYDRONEPHROSIS  AND  HYDROPERINEPHROSIS  (50) 
An  expansion  of  the  pelvis  of  the  kidney  by  retained  urine 
is  termed  hydronephrosis.  If  a  similar  collection  of  fluid  be  outside 
of  the  kidney,  but  of  the  same  nature  and  connected  with  the 
cavity  of  the  kidney,  I  think  it  may  be  appropriately  termed  a 
hydroperinephrosis.  For  its  origin  more  resembles  that  of  hydro- 
nephrosis than  of  congenital  cystic  kidney  or  of  hydatid  cysts,  or 
even  of  paranephric  cysts  with  which  it  has  usually  been  classed. 
Hydroperinephrosis  would,  therefore,  form  the  connecting  link 
between  hydronephrosis  and  the  cysts  of  the  kidney,  for  it  especially 
resembles  the  paranephric  cysts.  But  an  expansion  of  the  natural 
cavity  of  the  kidney  or  of  its  envelope,  outside  of  the  kidney,  is 
not  to  be  confused  with  cystic  growths  in  the  kidney  substance 
or  springing  from  surrounding  tissues.  Hydronephrosis  and  hydro- 
perinephrosis are  indistinguishable  clinically.  Either  of  them  may 
be  congenital  or  acquired  ;  and  the  acquired  disease  may  be  either 
traumatic  or  non-traumatic  in  its  origin.  One  or  both  kidneys 
may  be  affected.  They  are  caused  by  an  obstruction  to  an  outflow 
of  urine.    The  causes  of  the  obstruction  leading  to  acquired  h\(lro- 


656  SURGICAL   DISEASES    OF   CHILDREN 

nephrosis  or  hydroperinephrosis  may  be  within  the  water  pas- 
sage— such  as  impaction  of  a  calculus  in  the  urethra  or  ureter, 
small  cystic  growths  in  its  mucous  membrane,  fibromatous  growths, 
or  plugging  of  the  ureter  by  blood  clot;  or  may  be  caused  by  cica- 
tricial contraction  of  ureter  or  urethra;  or  from  injuries  by  external 
forces,  or  by  a  fold  or  kink  in  the  ureter  occasioned  by  traumatic 
dislocation  of  the  kidney,  or  by  pressure  of  a  tumor,  or  of  inflam- 
matory swelling  adjacent  to  the  ureter. 

Pathology. — In  hydronephrosis  the  pelvis  of  the  kidney  first 
expands  in  a  more  or  less  globular  form.  Pressure  upon  the 
medullary  substance  and  cortex  causes  them  to  atrophy  and  expand, 
together  with  the  kidney  capsule.  The  walls  of  the  sac  may  be 
thick  and  strong  or  thinned  and  delicate,  almost  to  bursting.  In 
some  instances  fibrous  septa  partially  divide  the  cavity;  or  in  cases 
of  hydroperinephrosis  a  portion  of  the  fluid,  perhaps  by  far  the 
greater  part  of  it,  has  apparently  forced  an  exit  through  the  wall 
surrounding  the  kidney  pelvis,  and.  accumulated  in  an  expanded 
sac  continuous  with  the  kidney  capsule.  The  opening  between  the 
collections  of  fluid  may  be  so  large  as  scarcely  to  separate  them 
into  two,  or  so  small  as  to  be  difficult  to  find. 

The  whole  diseased  kidney  may  expand  so  as  to  more  than  half 
fill  the  abdomen,  or  may  be  smaller  than  a  normal  kidney. 

The  fluid  contents  may  somewhat  resemble  urine,  altered  or 
diluted ;  and  be  found  by  appropriate  tests  to  contain  urea,  uric  acid, 
water,  or  oxalate  of  lime,  chlorides,  phosphates,  epithelial  cells, 
remains  of  blood  cells,  coloring  matter  and  fibrin,  albumen  and,  occa- 
sionally, cholesterin.  Any  or  several  of  these  may  be  found  in  a 
given  specimen  or  the  fluid  may  consist  of  nothing  but  water 
and  sodium  chloride,  and  be  colorless. 

Symptoms  and  Diagnosis. — Hydronephrosis  or  hydroperine- 
phrosis may  be  present  without  symptoms.  When  symptoms  are 
present  they  will  vary  with  the  cause,  and  there  is  none  character- 
istic until  tumor  becomes  appreciable.  The  symptoms  other  than 
that  of  tumor  are  those  of  obstruction  to  the  flow  of  urine  and  of 
the  disease  causing  the  obstruction. 

The  symptoms  of  obstruction  are  diminution  in  the  amount  of 
urine  passed,  frequent  attempts  at  micturition,  pain  in  the  lower 
abdomen,  and  thirst.  But  in  some  cases  there  are  occasional  dis- 
charges of  an  increased  quantity  of  urine.  Pain  may  not  be  pres- 
ent unless  'the  cause  of  the  obstruction  and  resulting  collection  of 
fluid  is  of  a  painful  nature.  If  both  kidneys  are  affected,  symptoms 
of  uremia  may  come — headache,  dizziness  or  dimness  of  vision,  or 
convulsions. 

No  age  from  fetal  to  senile  life  is  exempt.  Cases  in  females 
outnumber  those  in  males,  two  to  one. 


THE    GENITO-URINARY    ORGANS  657 

Prognosis. — The  prognosis  depends  upon  whether  one  or  both 
kidneys  are  involved  and  upon  the  nature  of  the  obstruction. 

Spontaneous  cures  have  taken  place,  the  accumulation  dis- 
charging itself  by  the  natural  passage  and  never  returning,  but 
this  is  not  by  any  means  to  be  depended  upon,  as  such  instances 
are  rare. 

Symptoms  of  uremia  are  very  grave.  Great  size  and  pres- 
sure of  the  tumor  call  for  prompt  interference,  as  the  tumor  may 
burst  internally,  with  fatal  result,  or  it  may  cause  death  by  pres- 
sure upon  stomach  or  intestines. 

Treatment. — Any  existing  obstruction  to  the  exit  of  urine, 
for  instance,  phimosis,  narrow  or  strictured  urethra,  calculus  or 
tumors,  in  or  pressing  upon  bladder  or  ureter,  should  be  relieved 
if  possible.  Hydronephrotic  or  hydroperinephrotic  tumor,  if  small 
and  occasioning  no  symptoms,  calls  for  no  immediate  interference. 
Cases  have  been  recorded  in  which  massage  or  manipulation  of  the 
tumor  led  to  a  discharge  of  the  fluid,  and  no  reaccumulation  fol- 
lowed. Great  caution  should  certainly  be  used  with  this  plan, 
especially  in  large  or  tensely  distended  tumors,  for  fear  of  rupture. 

Aspiration  is  a  method  much  advised  and  often  employed. 
One  or  several  repeated  aspirations  have  cured  cases.  Strict  anti- 
septic methods  should  be  observed  in  aspirating.  The  needle 
should  be  introduced  where  the  peritoneum  or  the  colon  does  not 
intervene  between  the  skin  and  the  tumor.  If  the  tumor  point  in 
the  loin  it  may  be  punctured  where  it  points.  Otherwise  it  is 
usually  punctured  about  half  way  between  the  last  rib  and  the  crest 
of  the  ilium,  and  just  outside  of  the  erector  muscles  of  the  spine. 
Others  prefer  to  enter  the  needle  just  in  front  of  the  last  inter- 
costal space.  The  needle  is  directed  forward  and  inward  toward 
the  center  of  the  enlargement.  It  is  not  advisable  to  introduce  any 
medicine  nor  any  antiseptic  into  the  cyst,  even  though  the  fluid 
withdrawn  appear  to  contain  pus. 

Aspiration  has  the  disadvantages  of  possibly  occasioning  leak- 
age from  the  cyst  into  the  tissues  and  resulting  in  inflammation ;  of 
giving  no  information  concerning  the  tissues  passed  through,  nor 
of  the  condition  of  the  kidney,  nor  of  the  nature  of  the  obstruction. 

Aspiration  or  repeated  aspirations  failing,  incision  or  ne- 
phrotomy should  be  resorted  to.  Some  surgeons  prefer  the  knife 
to  the  needle  as  the  first  resort.  The  incision  is  the  same  as  that 
for  nephrotomy.     (See  Figs.  16  and  17.) 

RENAL  CALCULUS 

While  small  renal  calculi,  usually  of  uric  acid,  are  very  com- 
mon in  infants  and  young  children,  it  is  seldom  that  trouble  occurs 
from  a  larger  stone.    The  small  calculi  are  passed  by  way  of  ureter 


6s8  SURGICAL   DISEASES    OF   CHILDREN 

and  urethra,  and  the  kidney  often  seems  quite  tolerant  of  calcuhis 
of  a  larger  size. 

Symptoms  and  Diagnosis. — Symptoms  are  the  same  as  in  the 
adult.  There  is  pain  in  the  loin  which,  in  boys,  is  apt  to  extend  into 
the  urethra  or  the  perineum  and  to  cause  retraction  of  the  testis. 
Pain  is  worse  after  exercise,  relieved  by  rest,  and  sometimes  re- 
ferred to  the  other  kidney.  There  may  be  tenderness  over  the 
affected  kidney,  or  at  least  the  pain  may  be  elicited  by  deep  palpa- 
tion or  sharp  percussion,  and  so  betray  which  of  the  two  is  really 
diseased.  Hematuria  is  a  common  symptom  and  is  apt  to  pass 
unnoticed  by  the  parents  until  serious  anuria  is  present.  There 
is  apt  to  be  a  trace  of  albumen  in  the  urine.  Or  nothing  abnormal 
may  be  found  but  high  specific  gravity  and  excessive  acidity. 
Sometimes,  instead  of  urates,  the  faulty  metabolism  manifests  itself 
in  the  form  of  oxalates.  Often  the  urine  is  passed  very  frequently, 
and  very  little  at  a  time.  When  it  is  retained  it  becomes  alkaline; 
when  infected,  purulent.  The  Roentgen  ray  should  always  be 
employed  in  diagnosis.  It  may  furnish  positive  evidence  for  diag- 
nosis in  lieu  of  much  that  is  ambiguous.  The  presence  of  pus, 
albumen,  or  blood  in  the  urine  points  to  renal  calculus  rather  than 
to  spinal  caries.  Tuberculosis  of  kidney  cannot  be  positively  ex- 
cluded by  microscopic  examination.  Inoculation  experiments  and 
the  tuberculin  test  should  be  employed  in  doubtful  cases.  A  his- 
tory of  the  symptoms  extending  over  several  years,  with  no  evi- 
dence of  tuberculosis  elsewhere,  favors  the  diagnosis  of  stone  in 
the  kidney.  Examination  under  anesthesia  may  reveal  alteration 
in  size,  shape,  or  situation  of  the  kidney. 

Treatment. — The  treatment  consists  of  rest,  and  sometimes 
anodynes  during  the  painful  exacerbations,  and.  of  the  persistent 
use  of  a  carefully  regulated  diet.  Drinking  freely  of  distilled  water, 
and,  in  those  cases  accompaned  by  acid  urine,  the  use  of  lithia  water 
or  other  mild  alkaline  mineral  water  is  beneficial. 

If  there  are  symptoms  of  stone  in  the  kidney,  with  pus  in  the 
urine,  and  rise  of  temperature  and  chills,  an  operation  is  indicated. 
If  the  symptoms  are  less  urgent,  but  the  disease  is  chronic,  and 
persistent  pain  is  present,  operation  is  in  order.  The  operation  will 
be  a  pyelolithotomy,  nephrolithotomy,  or  a  nephrectomy  or  partial 
nephrectomy,  according  to  the  location  of  the  stone  and  the  con- 
dition of  the  diseased  organ,  and  also  of  the  other  kidney.  If  the 
kidney  is  suppurating  it  should  be  drained  through  a  lumbar  in- 
cision. It  is  best  to  remove  a  stone  whole  if  possible;  if  frag- 
mented the  fragments  should  all  be  removed.  If  the  kidney  is 
suppurating  and  the  stone  cannot  be  found  at  once,  it  may  be 
searched  for  subsequently  after  drainage.  One  should  not  be  hasty 
in  sacrificing  a  kidney,  or  even  a  portion  of  a  kidney,  in  a  non- 


THE    GENITO-URINARY    ORGANS  659 

tubercular  pyelonephritis,  or  in  hydronephrosis  with  even  enor- 
mous distension.  When  an  exit  is  found  for  pus  or  urine,  the  recu- 
perative power  of  the  kidney  tissue  is  remarkable. 

TUBERCULAR    NEPHRITIS 

Tuberculous  nephritis  may  be  a  part  of  a  general  tuberculosis 
or  it  may  be  primary,  infection  having  taken  place  through  the 
blood.  The  disease  may  descend  to  other  portions  of  the  genito- 
urinary tract,  but  quite  often  it  remains  localized  in  the  one  kid- 
ney affected.  It  may  be  in  the  form  of  miliary  tuberculosis  of  the 
kidney-pelvis ;  or  in  foci  in  the  cortex  involving  the  mucous  lin- 
ings of  the  calices  and  pelvis.  Or  the  pyramids  may  become  the 
seat  of  caseous  masses  which  break  down  and  destroy  them,  often 
with  adjacent  portions  of  the  cortex,  and  break  through  the  cap- 
sule into  the  perinephric  tissues. 

Symptoms  and  Diagnosis. — The  symptoms  so  closely  resemble 
those  of  stone  in  the  kidney  that  the  diagnosis  between  them  is 
quite  difficult.  In  other  cases  they  are  so  indefinite  that  any  certain 
diagnosis  is  hard  to  make.  When  typical,  there  is  local  pain  and 
tenderness  in  the  region  of  the  kidney,  and  the  pain  is  less  apt 
to  be  paroxysmal  than  with  stone.  Reflex  irritation  of  the  blad- 
der, leading  to  frequent  micturition,  with  pain  while  passing  water, 
is  a  marked  symptom,  and  one  which  does  not  readily  yield  to 
medication,  which  would  relieve  irritability  from  other  causes.  The 
urine  usually  contains  pus,  often  blood,  and  sometimes  phosphates. 
If,  with  the  foregoing  symptoms,  tubercle  bacilli  are  found  in  the 
urine,  the  diagnosis  is  complete.  If  the  bacilli  are  not  found,  but 
the  tuberculin  test  is  positive,  one  is  justified  in  the  diagnosis ;  the 
bacilli  will  probably  be  found  later,  on  repeated  examinations. 
The  temperature  is  more  likely  to  be  of  a  typical  hectic  character 
than  with  pyonephrosis  from  calculus.  The  kidney  may  be  found 
enlarged,  especially  if  perinephritis  exist,  and  may  perhaps  be 
detected  on  percussion  and  palpation,  being  careful  to  distinguish 
between  an  enlarged  spleen  on  the  left  side  and  the  renal  and 
hepatic  dullness  on  the  right.  In  older  children,  particularly  in 
girls,  catheterization  of  the  ureters  may  determine  which  kidney 
is  affected. 

Prognosis. — The  prognosis  is  necessarily  grave;  and  yet  if 
one  could  be  sure  only  one  kidney  is  affected  there  is  a  fair  pros- 
pect of  recovery  after  operation. 

Treatment. — If  the  surgeon  is  convinced  that  only  one  kidney 
is  aft'ectcd,  it  should  be  promptly  removed.  If  there  is  doubt 
about  the  soundness  of  the  other  kidney  the  certainly  diseased  one 
may  be  opened  and  drained  until  the  next  step  can  be  deter- 
mined. 


OtXJ 


SURGICAL   DISEASES    OF   CHILDREN 


TUMORS  OF  THE  KIDNEY 

Innocent  Tumors. — Tumors  of  the  kidney  are  innocent  or 
malignant.  The  innocent  tumors  are  less  frequent  than  the  malig- 
nant They  are  apt  to  be  fibromata  or  fibrocystic  growths.  Der- 
moids are  occasionally  found. 
Symptoms  and  Diagnosis. 
— Innocent  tumors  give  rise 
to  no  symptoms,  excepting, 
perhaps,  occasional  hema- 
turia, unless  they  attain  con- 
siderable size.  They  grow- 
slowly,  occasion  pain  only  in 
case  of  pressure,  cause  no 
constitutional  symptoms,  and 
are  less  apt  to  give  rise  to 
local  peritonitis  and  effusion 
than  malignant  growths. 

Treatment.  —  Removal  is 
necessary  if  they  interfere 
with  other  organs  or  struc- 
tures. 

Malignant  Tumor  s. — 
Malignant  tumors  form  the 
greater  number  of  all  the 
tumors  of  the  kidney;  of  all 
the  malignant  tumors  of  the 
abdomen  those  connected  with 
the  kidneys  are  most  common. 
And  of  all  the  malignant 
tumors  of  the  kidney  the 
greater  number  are  sarco- 
mata. They  may  sometimes 
be  described  as  round-celled, 
spindle-celled,  or  rhabdo-myo- 
sarcoma,but  are  more  apt  to  be 
atypical.  They  may  even  have 
the  structure  of  innocent  tu- 


FiG.  226.  Sarcoma  of  kidney.  Ascites. 
Tumor  friable,  bleeding  at  a  touch. 
Blood  free  in  the  abdomen.  Died 
the  next  day  after  extirpation.  Boy 
S  years  old.    Dr.  A.  F.  House's  case. 


mors,  but  the  character  of  malignancy.  The  tumor  may  infiltrate 
the  kidney  parenchyma,  but  frequently  there  is  a  capsule,  or  it 
may  spring  from  the  pelvis,  or  from  the  cortex,  and  not 
infrequently  from  the  adrenals.  The  tumor  may  be  so  soft  as 
to  give  the  examining  hand  the  impression  of  fluctuation,  and 
so  friable  as  to  bleed  spontaneously  or  from  handling  during 
examination.    A  malignant  growth  is  apt  to  adhere  to  surrounding 


THE    GENITO-URINARY    ORGANS 


66i 


organs,  to  excite  local  peritonitis  and  ascites.  (See  Figs.  226 
and  227.)  Secondary  tumors  may  be  found  in  the  tissues 
near  by  or  more  remote,  not  so  frequently  in  the  intestines  or 
pancreas,  but  in  the  opposite  kidney,  in  the  liver  or  in  the  lungs ; 
and  very  early  in  the  retro-peritoneal  glands,  especially  if  there 
be  carcinomatous  elements  in  the  tumor.  The  tumor  may  attain 
large,  or  even  immense,  size  and  cause  damaging  pressure  upon  sur- 
rounding structures.  The  etiology  and  pathology  are  discussed  in 
the  chapter  on  tumors.  Malignant  tumors  of  the  kidney  are  often 
congenital,  and  nearly  always  occur  in  early  childhood.  Traumatism 
seems  to  be  the  exciting  cause  of  the  growth  in  a  few  cases. 

Symptoms  and  Diagnosis. — Generally,  tumor  is  the  first  symp- 
tom observed.    It  may  be  discovered  in  the  loin  if  there  is  any  oc- 
casion for  an  examination.     But  usually  there  is  no  other  symptom 
to    attract    attention    while 
the  tumor  is  yet  small  ex- 
cept   it   be    hematuria.     In 
a    few    cases    the    amount 
of   blood    lost   may    be    so 
large   as  to   be   noticed    by 
the    family,    or    it   may    be 
small  in  amount  and   only 
discovered      after      micro- 
scopic search.     In  the  ma- 
jority of  cases   the   tumor 
is    discovered    only    when 
the  abdomen  enlarges,  for 
the   tumor   does   not  bulge 
laterally  as   much   as   forward 
months  may  fill  the  abdomen. 


Fig.  227.  Sarcoma  and  kidney  from 
the  case  shown  in  Fig.  226.  Histo- 
logically it  proved  to  be  of  mixed 
types. 


It  grows  rapidly  and  in  a  few 
Its  surface  may  be  quite  smooth, 
or  it  may  be  lobulated  or  nodulated.  It  may  be  quite  sym- 
metrical or  irregular  in  outline.  Although  solid,  it  may  be  so  soft 
as  to  give  a  pseudo-fluctuation.  Pressure  upon  the  ureter  may  re- 
tain the  secretion  of  the  kidney  in  its  pelvis  and  cause  hydro- 
nephrosis which  adds  to  the  abdominal  enlargement  and  obscures 
the  physical  diagnosis.  Edema  of  the  lower  extremities  may  occur, 
as  in  all  cases  of  intra-abdominal  tension,  by  pressure  on  the  vena 
cava;  but  with  a  solid  tumor  of  the  kidney  this  sympton  may  be 
quite  marked  and  thrombosis  may  occur.  When  an  abdominal  tumor 
is  small  its  point  of  attachment  may  be  demonstrated,  but  when  it 
is  large  this  may  be  impossible,  on  account  of  its  size,  the  tension 
of  the  abdominal  walls  and  sometimes  by  adhesions  to  surrounding 
structures  which  interfere  with  its  mobility.  The  location  of  the 
attachment  is  a  point  one  is  very  anxious  to  discover,  for  the 
tumor  may  be  in  connection  with  a  kidney  or  an  ovary,  or  with  the 


662  SURGICAL   DISEASES    OF    CHILDREN 

liver  or  spleen,  or  with  the  abdominal  walls.  Or  it  may  be  only 
an  enlargement  of  the  spleen.  Even  when  proven  to  be  in  connection 
with  the  kidney,  it  remains  to  be  decided  whether  the  tumor  is  a 
hydronephrosis  or  hydroperinephrosis,  possibly  an  abscess,  or  a 
new  growth,  and  whether  innocent  or  malignant.  With  abscess 
the  enlargement  is  more  localized  in  the  loin  and  there  are  more 
symptoms  of  inflammation.  Hydronephrosis  and  hydroperine- 
phrosis show  diminished  amount  of  urine  passed.  Innocent  tumors 
are  of  slower  growth  and  not  accompanied  by  cachexia.  Pain  is 
not  a  common  symptom,  even  with  malignant  tumor,  and  may 
only  be  present  when  local  peritonitis  occurs.  General  peritonitis 
is  unusual,  and  there  is  no  generalized  tenderness  over  the  abdo- 
men. The  pressure  within  the  abdomen  produces  dyspnea  from 
interference  with  the  movements  of  the  diaphragm.  Pressure  upon 
the  stomach  and  intestines  produces  symptoms  of  interference  with 
their  functions.  Cachexia  does  not  make  its  appearance  early  in 
the  case,  but  after  the  tumor  attains  considerable  size  it  becomes 
evident;  and  when  the  functions  of  the  digestive  organs  are  inter- 
fered with,  wasting  becomes  rapid. 

Prognosis. — Without  operation,  the  fatal  termination  may  be 
looked  for  in  from  three  to  twelve  months  after  the  tumor  is 
discovered.  With  operation  the  prognosis  is  still  very  grave,  and 
yet  not  hopeless.  All  studies  of  the  subject  point  to  the  necessity 
of  early  discovery  of  the  tumor  and  recognition  of  its  nature,  and 
to  early  operation  before  secondary  growths  render  removal  futile 
or  involvement  of  surrounding  structures  makes  it  impossible,  for 
only  in  operation  lies  any  brightening  of  the  dark  prognosis. 

Treatment. — Treatment  is  by  removal  of  the  tumor.  The 
removal  of  the  tumor,  and  generally  of  the  kidney  with  it,  is  so 
severe  for  a  child  so  young — often  only  two  or  three  years  of  age, 
and  hardly  ever  older  than  five  years — that  every  means  must  be 
used  to  fortify  the  patient  against  shock  and  hemorrhage.  It  is 
well  to  prepare  him  with  tonics  and  hematinics.  At  the  time  of 
the  operation,  abundance  of  artificial  heat  must  be  supplied,  and 
preparation  made  for  intravenous  injection  of  normal  saline  solu- 
tion. The  patient  is  kept  with  his  head  lowered  both  during  and 
for  some  days  after  the  operation.  (Abbe.)  During  the  operation 
especial  care  should  be  taken  to  prevent  loss  of  blood.  A  vertical 
incision  in  the  loin  does  not  afiford  sufficient  room  to  get  at  the 
kidney  in  a  child.  My  own  preference  is  for  an  incision  nearly 
transverse,  below  and  parallel  to  the  last  rib.  This  incision  can  be 
extended  forward  as  far  as  it  is  found  necessary.  This  incision  has 
an  advantage  if  there  is  any  question  that  the  tumor  may  be  a 
hydronephrosis  or  hydroperinephrosis,  or  a  retroperitoneal  tumor 
not  connected  with  the  kidney.     If  the  tumor  is  very  large  the 


THE    GENITO-URINARY    ORGANS  663 

incision  may  be  made  vertically,  in  the  semilunar  line.  This  lat- 
ter incision  might  be  chosen  if  there  was  a  question  of  the  tumor 
being  connected  with  an  ovary  instead  of  kidney.  If  the  abdomen 
is  opened  by  the  last  mentioned  incision  the  colon  should  be  dis- 
placed toward  the  middle  line ;  that  is,  the  peritoneum  should  be 
opened  behind  the  colon,  in  order  to  get  at  the  kidney  and  the 
tumor  attached  to  it.  An  attempt  should  be  made  to  follow  the 
capsule  of  the  tumor  if  it  has  any,  in  the  enucleation,  and  the  rule 
is  to  remove  too  much  rather  than  too  little  tissue.  If  the  kidney, 
also,  is  to  be  removed,  the  tumor  and  the  kidney  are  separated  all 
round  by  blunt  dissection,  until  it  is  held  only  by^  the  vessels  and 
the  ureter.  These  are  identified  and  separated  and  a  double  liga- 
ture of  silk  or  strong  catgut  passed  between  them.  One  ligature 
is  then  tied  around  the  vessels  as  far  as  possible  from  the  kidney, 
and  the  other  is  tied  around  the  ureter.  A  he'mostat  or  a  pedicle 
clamp  is  then  placed  upon  the  pedicle  of  the  kidney  and,  the  kidney 
divided  so  as  to  leave  the  stump  of  the  pedicle  clamped.  It  should 
now  be  made  sure  that  the  vessels  are  securely  tied  and  the  liga- 
ture cannot  slip,  and  the  forceps  may  be  removed.  If  the  tumor  is 
very  large  it  is  often  better  to  place  forceps  upon  vessels  and  ureter 
and  remove  the  mass  before  ligating.  In  making  the  dissection, 
all  tissues  which  may  contain  vessels  should  be  seized  with  hemo- 
stats  and  divided  between.  The  supr^arenal  capsule,  also,  should 
be  removed.  It  is  essential  to  remove  the  fatty  capsule  of  the  kid- 
ney, if  there  be  one.  Quite  often  there  is  none  in  evidence.  The 
cavity  is  now  inspected  and  dried  and  all  bleeding  points  secured. 
The  cavity  is  packed  with  sterile  gauze  and  closed  with  gauze 
drainage,  or,  if  preferred,  with  tube  drainage.  If  the  anterior 
incision  has  been  used,  posterior  drainage  may  be  supplied  by  open- 
ing from  the  inside  out  through  the  loin.  The  incision  is  now 
closed.  The  child  is  given  a  coiTee  saline  by  the  rectum  or  a  saline 
by  a  vein  or  subcutaneously,  and  strychnia  or  camphor  under  the 
skin,  and  put  to  bed,  head  low,  with  hot-water  bottles.  The  gauze 
packing  is  removed  after  two  days,  and,  if  the  wound  is  clean, 
need  not  be  renewed. 

EXTROVERSION    OF    THE    BLADDER    (ECTOPIA    VESICffi:) 

This  malformation  occurs  most  often  in  the  male.  A  hiatus 
in  the  abdominal  wall  by  a  failure  of  the  ventral  laminns  of  the 
embryo  to  meet  in  the  middle  line  causes  the  anterior  half  of  the 
bladder  to  be  lacking.  In  its  place  there  is  an  area  of  red  and 
spongy  or  velvety,  sometimes  rugous-looking,  mucous  membrane, 
constantly  wet  with  urine  and  often  chafed  and  inflamed  by  the 
clothing  or  crusted  with  phosphatic  deposits.  This  red  area  is  the 
posterior  wall  of  the  bladder.     It  may  be  slightly  concave,  but  is 


664  SURGICAL   DISEASES    OF   CHILDREN 

quite  as  frequently  level  with  the  skin  surface,  or  even  protruding 
beyond  it.  (See  Fig.  228.)  At  its  lower  margin  may  usually  be 
found  a  rudimentary  penis,  or  the  glans  without  the  urethra,  or 
malformed  almost  beyond  recognition.  The  corpora  cavernosa  are 
usually  deficient,  and,  the  corpus  spongiosum  not  having  united, 
the  urethra  is  only  represented  by  its  floor  shown  upon  the  dor- 
sum of  the  rudimentary  penis.  This  is  turned  up  against  the  ex- 
posed mucous  membrane,  which  represents  the  trigone  and  more  or 


Fig.  228.  Extroversion  of  the  bladder  and  right  inguinal  hernia.  Boy 
2i  years  old.  The  dark  surface  is  the  mucus  membrane  of  the  posterior 
wall  of  the  bladder.  The  epispadiac  glans  penis  and  the  prepuce  below 
it  can  be  distinguished. 

less  of  the  posterior  surface  of  the  bladder.  The  scrotum  is  poorly 
developed.  The  testes  may  have  descended  into  it  or  they  may 
have  lodged  in  the  inguinal  canals.  Just  behind  the  glans  penis 
the  urine  trickles  out,  and  by  tracing  its  point  of  appearance  the 
openings  of  the  ureters  may  be  seen.  The  parts  adjacent  and  the 
clothing  are  constantly  wetted  with  urine ;  the  skin  often  is  excori- 
ated or  eczematous. 

This  malformation  is  often  accompanied  by  one  or  more  others ; 
for  example:  The  umbilicus  is  apt  to  be  lower  than  normal  upon 
the  abdomen ;  the  pubic  bones  may  have  failed  to  unite  properly  at 
the  symphisis,  having  only  a  fibrous  union ;  inguinal  hernia,  single 
or  double,  is  not  uncommon  and  very  troublesome  to  truss  on 
account  of  the  wet  and  often  inflamed  skin  surface ;  the  anus  may 
be  farther  forward  than  usual ;  the  genitals  may  be  so  malformed 
as  to  make  the  sex  indistinguishable;  the  rectum,  with  a  long,  loose 
mesentery,  may  be  prolapsed.     There  are  different  grades  of  the 


THE    GENITO-URINARY    ORGANS 


66- 


deformity,  the  condition  already  described  being-  the  third  grade, 
which  is  the  most  ordinary.  (Champneys,  Ashby  and  Wright.) 
In  the  first  or  shghtest  grade  there  is  shght  separation  of  the 
symphysis,  and  perhaps  a  hernial  pouch,  but  no  deficiency  of 
the  bladder.  In  the  second,  prolapse  of  the  bladder,  perhaps  through 
the  urethra  or  urachus.    (Vro- 

lik,    Froriep.)      In    the    fourth  r -, 

the  bladder  not  only  is  lacking  ;     q     ; 

in  its  anterior  wall,  but  is  di- 
vided into  two  lateral  portions, 
with  the  opening  of  the  intes- 
tine between  them. 

Diagnosis. — The  third  de- 
gree, the  most  ordinary  form, 
as  before  described,  is  recog- 
nized without  difficulty. 

Treatment. — Relief  for  this 
malformation  has  so  far  proved 
a  baffling  problem.  It  is  im- 
possible to  attach  to  the  parts 
any  form  of  apparatus  to  catch 
the  urine.  Very  numerous 
operations  have  been  planned 
and  tried.  They  may  be  di- 
vided into  two  general  classes, 
each  with  several  varieties. 

Class  I. — In  the  first  class 
are  those  operations  designed 
to  construct  a  receptacle  having 
no  sphincter,  but  of  such  shape 
that  an  apparatus  can  be  at- 
tached to  catch  the  urine. 

Class    2. — In    the    second 
class  are  operations  to  deliver  the  urine  from  the  ureters  into  the 
intestine. 

As  varieties  of  Class  I  will  be  mentioned  variety  A.,  Wood's 
operation,  which  is  intended  to  provide  an  anterior  wall  for  the  blad- 
der, by  dissecting  up  a  skin  flap  from  the  abdomen,  turning  it  down 
over  the  bladder  and  closing  the  sides  with  lateral  flaps  turned  across 
toward  the  middle  line  from  the  groins.  The  diagrams  and  descrip- 
tion of  Wood's  operation  are  modified  from  Binnie,  Operative  Sur- 
gery. (See  Figs.  229  and  230.)  Flap  A  is  dissected  from  the  skin 
of  the  abdomen  and  has  its  base  near  the  bladder.  In  dissecting 
off  this  flap  it  should  not  be  loosened  within  one-fourth  of  an  inch 
of  the  margin  of  the  bladder  membrane.  In  this,  as  in  all  similar 
operations,  the  flaps  should  be  quite  a  good  deal  larger  than  the 


Fig.  229.  Wood's  operation  for 
extroversion  of  the  bladder, 
outline  of  flaps. — Drawing  modi- 
fied from  Binnie's  Operative  Sur- 
gery. 


666 


SURGICAL   DISEASES    OF   CHILDREN 


surface  to  be  covered,  as  there  is  certain  to  be  a  shrinking  of  the 
flap.  If  the  urethral  gutter  on  the  dorsum  of  the  penis  is  to  be 
closed  in,  flap  A  is  extended  as  in  D  in  the  diagram,  leaving  it 
attached  to  flap  A,  that  is,  all  in  one  piece.  (Greig  Smith.)  Flaps 
B  and  C  are  then  cut  from  the  abdominal  wall,  one  at  each  side 

of  flap  A  and  having  their 
bases  iDelow.  The  margins  of 
the  bladder  are  freshened,  ex- 
cepting opposite  the  hinge  of 
flap  A,  and  where  the  urethral 
gutter  leaves  the  bladder  to  ex- 
tend along  the  penis.  Flap  A 
is  turned  downward,  with  its 
epithelial  surface  lining  the  an- 
terior wall  thus  made  for  the 
bladder,  and  its  raw  surface 
outward.  The  edge  of  the  flap 
is  sutured  securely  to  the  fresh- 
ened edge  of  the  bladder.  Flap 
C  is  then  slid  around  so  as  to 
cover  half  the  raw  surface  of 
flap  A.  Flap  B  is  then  used 
the  same  on  the  opposite  side, 
and  both  lateral  flaps  are  su- 
tured in  position.  If  flap  D  is 
to  be  used  it  is  sutured  to  the 
freshened  edges  of  the  penile 
urethral  gutter  and  its  raw 
surface  covered  by  a  bridge-flap 

from    the    prepuce.     The    raw 
Fig.  210.    Wood's  operation  for  ex-  ^  '^  ,  ,,        ,  ,^ 

TRovERsioN  OF  THE  BLADDER.  The  surfaccs  made  upon  the  abdo- 
flaps  applied.  The  raw  surface  of  men  by  the  removal  of  these 
flap  D  still  remains  to  be  covered  ^  ^^^  p^^tly  covered  by  slid- 
by  bringing  up   a  bndge-tlap   from    .     ^     .  ,      ,,  ,. 

the  prepuce.— Drawing  modified  mg  mward  the  surroundmg 
from    Binnie's    Operative    Surgery,    skin     and     the     remainder     by 

Thiersch  grafts. 
The  objections  to  this  operation  and  others  like  it  are,  that 
there  is  such  extensive  dissection  and  consequent  scarring,  even 
if  there  is  no  sloughing  of  the  large  flaps ;  and  also  that  the  epider- 
mal surface  which  is  turned  inward  is  liable  to  grow  hairs  which 
prove  very  irritating  and  troublesome.  Yet  this  is  a  representative 
variety  of  the  class  of  operations  which  have  most  frequently  been 
done  for  this  malformation. 

Variety  B.,  in  which  the  object  is  to  unite  the  sides  of  the  ex- 
posed bladder  surface  so  as  to  make  a  small  receptacle  but  one 


THE    GENITO-URINARY    ORGANS 


e(i^ 


lined  with  the  mucous  membrane  of  the  bladder.  In  Trendclenberg-'s 
operation  the  sacro-iliac  synchondroses  are  opened  and  divided  so 
that  the  pubic  bones  can  be  brought  together,  and  the  abdominal 
walls  relaxed  in  the  middle  line,  after  which  the  lateral  margins  of 
the  bladder  surface  are  freshened  and  united.  This  has  given  some 
good   results. 

Finding  separation  of  the  synchondroses  difficult  and  dangerous. 
Perkins      divided     the     ilium 
close     to     the     synchondrosis 
with   the   chisel   and   obtained 
the  same  result.     (Binnie.) 

Variety  C. — In  this  op- 
eration, which  bears  the  name  ^^ 
of  Schlange,  the  portions  of 
the  pubis  to  which  the  recti 
muscles  are  attached  is  chis- 
eled loose,  thus  permitting 
their  approximation  and  the 
union  of  the  transplanted 
portions  of  bone  and  of  the 
inner  margins  of  the  muscles. 

Konig's  operation  is  simi- 
lar, but  the  horizontal  and 
descending  rami  of  the  pubis 
are  divided  to  allow  of  the  ap- 
proximation. 

Very  numerous  varieties 
of  flap  operations  have  been 
executed,  some  of  them  very 
ingenious.  The  flaps  taken 
from  the  sides  of  the  hiatus 
as  well  as  from  above,  and 
also  from  below,  utilizing  the 
scrotum  and  the  prepuce  as  flap  material. 

Variety  D. — This  one  of  the  varieties  of  Class  I,  Rutkowski's 
operation,  involves  a  different  principle,  seeking  to  construct  an  an- 
terior wall  from  flap  material  of  a  section  taken  from  the  ileum 
(still  keeping  its  mesenteric  attachment),  thus  providing  a  bladder 
lined  with  mucous  membrane.  It  was  hoped  this  mucous  lining 
would  prevent  phosphatic  deposits,  but  such  is  not  the  case. 

Variety  E. — There  is  another  variety  of  operation,  Segond's,  in 
which  the  exposed  mucous  lining  of  the  bladder  is  made  to  cover 
the  upper  surface  of  the  penis,  converting  the  gutterlike  floor  of 
the  urethra  into  a  closed  canal.  (See  Fig.  231.)  It  is  performed 
as  follows :    An  incision  is  carried  around  three-quarters  of  the  cir- 


FiG.  231.  Second's  Operation.  _  A 
is  a  raw  surface  left  after  turning 
down  the  flap  B.  B  is  the  flap 
composed  of  the  posterior  wall  of 
the  bladder  with  its  mucous  side 
downward  covering  in  the  groove 
in  the  penis.  C  is  the  glans  penis. 
D  is  the  usually  reduntant  pre- 
puce with  an  incision  making  a 
bridge-flap  which  is  to  be  brought 
up  over  the  raw  surface  of  flap  B. 


668  SURGICAL   DISEASES    OF   CHILDREN 

cumference  of  the  exposed  mucous  area  and  dissected  loose,  leaving 
one-fourth  attached  at  the  lower  side  of  the  flap.  This  flap  is  turned 
down  upon  the  upper  surface  of  the  penis.  The  margins  of  the 
urethral  gutter  along  the  upper  surface  of  the  penis  are  then  fresh- 
ened and  the  flap  which  was  turned  down  is  sutured  at  its  margins 
to  these  freshened  edges.  The  prepuce,  which  hangs  below  the 
gians,  can  then  be  incised  transversely,  leaving  it  attached  at  both 
ends  and  can  be  brought  over  the  top  of  the  new  flap  with  the  raw 
surfaces  together  and  the  skin-side  out.  This  operation  has  the 
advantage  of  getting  rid  of  the  filthy  mucous  membrane,  making 
the  least  possible  wound  and  amount  of  scar,  and  of  having  the 
mucous  membrane  for  the  bladder-lining.  But  the  penis  is  often  so 
stunted  that  it  is  practically  impossible  to  work  with  it  in  the  manner 
described.  And  none  of  these  operations  provide  any  sphincter  for 
the  reconstructed  bladder.  The  urine  runs  from  its  lower  portion 
as  before,  but  can  be  collected  into  an  attached  urinal. 

We  will  now  turn  to  Class  II  of  the  operations  for  ectopia 
vesicae,  and  mention  two  varieties  and  describe  one  of  them  more 
fully. 

Variety  A. — In  this  variety  of  operation  the  ureters  are  de- 
tached from  the  vesical  wall  and  transplanted  into  the  rectum  or 
into  the  sigmoid  flexure  of  the  colon ;  so  that  the  urine  collects  in 
the  bowel,  which  becomes  tolerant  of  its  presence  and  is  controlled 
very  well  by  the  sphincter  ani.  This  procedure  is  correct  theoreti- 
cally and  has  been  successfully  executed  in  practice.  But  it  has  in- 
variably been  followed  by  fatal  septic  inflammation  traveling  up  the 
ureters  to  the  kidneys. 

Variety  B. — Maydl's  operation  is  another  and  a  better  variety  of 
the  operations  of  Class  II,  and  is  performed  as  follows  (Binnie)  : 
The  exposed  mucous  membrane  of  the  bladder  is  all  excised  ex- 
cepting an  elliptical  area  containing  the  orifices  of  the  ureters.  The 
whole  field  of  operation  is  then  cleansed.  The  abdomen  is  opened 
and  a  loop  of  the  sigmoid  flexure  is  brought  out  at  the  wound. 
The  gut  is  emptied  of  its  contents  by  stripping,  and  clamped  above 
and  below  the  loop  to  be  used.  The  gut  is  then  opened  longitudinally 
by  an  incision  of  suitable  length  and  the  margins  of  this  opening 
are  united  to  the  portion  of  bladder  wall  containing  the  ureters  by 
through  and  through  sutures.  This  line  of  sutures  is  then  to  be 
covered  by  a  line  of  continuous  Lembert  sutures ;  so  that  the  ellipti- 
cal portion  of  bladder  wall  is  inserted  like  a  patch  into  the  opening 
in  the  wall  of  the  gut.  Thus  the  ureters  open  into  the  sigmoid 
flexure.  The  normal  valves  or  sphincters  of  the  ureters  have  not 
been  destroyed  or  disturbed,  and  they  prevent  return  flow  and  ascend- 
ing infection  of  the  ureters.  This  operation,  like  the  others,  has  many 
modifications. 


THE    GENITO-URINARY    ORGANS 


669 


Of  these  operations,  those  of  Class  II  are  founded  upon  the 
better  principles,  and  Variety  B.,  that  is,  Maydl's  operation,  comes 
nearest  the  ideal.  It  is  more  difficult  of  execution  and  more  dan- 
gerous than  varieties  A.  or  C.  of  Class  I. 

In  Class  I,  Variety  E.,  Segond's  operation,  has  much  to  recom- 
mend it  and  would  be  the  operation  of  choice  in  a  case  upon  which 
it  could  be  executed.  It 
is  far  less  severe  than 
Maydl's  operation,  involves 
less  danger  and  shock  and 
could  be  risked  in  a  much 
weaker  or  younger  child. 
None  of  these  operations 
should  be  done  until  the 
child  is  three  or  four  years 
old.  But  the  condition  is 
so  harassing  that  every 
child  afflicted  with  it  should 
be  given  the  benefit  of 
operative  aid.  Fig.  232 
from  Ashby  and  Wright 
shows  an  excellent  result 
from  an  operation  of  Class 
I.  A  urinal  can  be  worn 
over  the  orifice  as  now 
formed.   One  of  the  annoy- 


FiG.  232.  Result  after  an  operation  of 
Class  I  for  ectopia  vesicas.  After 
Ashby  and  Wright. 


ances  of  such  cases  is  the  constant  accumulation  of  phosphatic 
deposits  about  the  parts.  To  prevent  or  lessen  this  Ashby  and 
Wright  recommend  the  use  of  a  wash  composed  as  follows :  Hydro- 
chloric acid,  twenty  minims;  glycerine,  one  drachm;  water,  one 
ounce.  If,  however,  the  deposit  persists  it  may  be  scraped  away 
occasionally  with  a  sharp  spoon.  Some  have  recommended  scrap- 
ing or  dissecting  off  all  the  mucous  lining  of  the  bladder  excepting 
that  just  about  the  ureters,  in  order  to  avoid  the  secretion  of  mucus. 


TUMORS  OF  THE  BLADDER 

Tumors  of  the  bladder  are  rare  in  children.  The  majority  of 
them  are  sarcomata.  Mucous  polypi  and  papillomata  have  been  re- 
ported. (Giraldes,  Birkett,  Owen,  Shattuck.)  Cancer  is  exceedingly 
rare. 

Symptoms  and  Diagnosis. — The  symptoms  are  frequent  desire 
to  micturate,  often  accompanied  by  difficulty  in  so  doing,  and  with 
pain  while  passing  water  and  between  times.  Hematuria  may  or 
may  not  be  present ;  but  is  very  apt  to  occur  after  sounding  the  blad- 


670  SURGICAL   DISEASES    OF   CHILDREN 

der.  The  diagnosis  from  stone  should  be  attempted  by  sounding ; 
from  tuberculosis  by  the  microscope;  from  cystitis  by  examination 
of  the  urine.  Tumor  and  cystitis  or  stone  and  cystitis  may  coexist. 
Tumor  may  occasion  retention  of  urine ;  or  tumor  may  simulate  re- 
tention. The  bladder  may  appear  distended  and  dull  on  percussion 
as  if  distended  with  urine,  but  the  catheter  being  passed  finds  little 
urine  there.  The  enlargement  and  the  dullness  is  due  to  the  sarco-' 
matous  mass  and  the  thickening  of  the  bladder  walls  which  it  pro- 
duces. A  polypus  or  a  portion  of  a  larger  tumor  may  protrude 
through  the  shorter  and  wider  female  urethra.  In  the  girl,  instead 
of  sounding,  the  urethra  may  be  dilated  and  a  digital  exploration 
made.  With  an  index  finger  in  the  rectum  and  the  opposite  hand 
over  the  pubes,  tumor  in  the  bladder  may  sometimes  be  detected,  or  it 
may  not  be  detected  even  when  present.  It  may  be  impossible  to  dis- 
tinguish whether  an  object  felt  upon  bimanual  examination  is  a  stone 
in  the  bladder  or  a  tumor,  or  whether  a  thickened  bladder  wall  is  due 
to  inflammation  or  to  infiltration  with  a  new  growth.  Yet  this 
method  of  examination  should  always  be  employed.  (51) 

Prognosis. — No  prognosis  can  be  made  until  one  is  sure  of  the 
nature  of  the  tumor,  and  in  the  majority  of  the  cases  this  can  only 
be  surmised  until  after  operation.  Given  an  innocent  tumor  there 
is  a  fair  prospect  of  dealing  with  it  successfully.  If  malignancy  is 
discovered  the  prognosis  is  very  dark  indeed.  The  course  of  the 
disease  is  so  rapid  that  by  the  time  the  diagnosis  is  made  the  disease 
has  gained  such  headway  that  complete  removal  is  impossible  or  is 
followed  by  recurrence  which  proves  fatal  in  a  few  months. 

Treatment. — A  small  tumor  may  sometimes  be  removed  through 
the  urethra  in  a  girl.  In  boys,  or,  with  any  but  very  small  tumors 
in  girls,  a  supra-pubic  cystotomy  should  be  done  in  the  same  man- 
ner as  for  stone  in  the  bladder,  and  the  tumor  excised. 

STONE  IN  THE  BLADDER 

Stone  in  the  bladder  is  much  more  prevalent  in  some  countries 
than  in  others ;  for  instance,  it  is  more  prevalent  in  Europe  than  in 
America,  and  in  India  than  in  Europe.  Certain  parts  of  a  country 
often  furnish  an  unusually  large  number  of  cases.  It  appears  as  a 
hereditary  disease  in  some  families  with  gouty  or  rheumatic  tenden- 
cies. It  has  been  said  that  one-half  of  the  entire  number  of  cases 
of  stone  in  the  bladder  occur  in  patients  under  puberty  (which  is 
probably  not  true  in  this  country)  ;  and  yet  it  is  rare  in  infancy, 
which  places  in  the  periods  of  childhood  and  youth  a  large  number 
of  the  cases  of  stone  occurring  in  a  given  locality.  There  are  found 
twenty  times  more  cases  of  stone  in  the  bladder  in  boys  than  in 
girls,  the  stone  escaping  when  small  from  the  short  and  distensible 
female  urethra. 


THE    GENITO-URINARY    ORGANS  671 

A^esical  calculus  in  the  young  patient  is  most  frequently  com- 
posed of  uric  acid  or  urates,  amorphous  or  crystalline,  the  concretion 
forming  upon  or  with  the  mucus  of  the  urinary  tract.  Phosphates 
and  other  salts  may  be  in  combination,  but  this  is  rare ;  and  in  rare 
instances  also  the  nidus  may  be  a  spicule  of  bone  from  caries  con- 
nected by  fistula  with  the  urinary  tract.  It  is  probable  that  in  the 
majority  of  instances  the  calculus  has  its  origin  in  the  kidney  from 
which  it  is  washed  when  small  into  the  bladder,  where  it  increases 
in  size  and  gives  rise  to  symptoms. 

Calculi  vary  in  shape,  being  sometimes  oval  and  smooth,  some- 
times spindle  or  oat-shaped,  and  again  irregular  in  outline  or  with 
rough  surfaces.  They  vary  in  size  from  that  of  an  oat  or  a  lentil  to 
that  of  a  cherry  or  almond  or  larger.  ]\Iore  than  one  may  be  pres- 
ent in  the  same  bladder. 

Symptoms. — The  symptoms  of  vesical  calculus  are  usually  acute 
and  well  marked  in  the  young.  This  is  due  to  the  extreme  sensi- 
tiveness of  the  mucous  lining  and  the  activity  of  the  reflexes ;  and 
in  part  to  the  pyramidal  shape  of  the  bladder  which  causes  the  stone 
to  gravitate  to  the  trigone,  where  it  produces  the  greatest  irritation 
and  is  frequently  caught  by  the  contracting  muscular  fibers,  pro- 
ducing severe  pain,  and  where  it  often  suddenly  obstructs  the  out- 
flow of  the  urine.  Thus  there  is  frequent  micturition,  with  a  sudden 
stoppage  of  the  stream,  and  vesical  tenesmus  and  pain,  often  caus- 
ing the  boy  to  cry  out  or  dance  about  and  pull  at  the  prepuce  during 
urination,  which  may  sometimes  be  followed  by  the  passage  of  a 
few  drops  of  blood.  The  irritation  and  frequent  desire  to  micturate 
are  not  troublesome  at  night  or  when  lying  down.  They  are  aggra- 
vated by  active  exercise.  The  vesical  tenesmus  may  excite  rectal 
tenesmus,  and  this  may  cause  prolapse  of  the  rectum.  Hernia  may 
result  from  straining. 

Diagnosis. — In  the  presence  of  the  foregoing  symptoms  one 
should  exclude  other  possible  causes  of  similar  irritation  and  pain, 
such  as  phimosis,  narrow  meatus  urinarius,  retained  smegma,  im- 
pacted urethral  calculus,  pyelitis,  rectal  polypus,  oxyurides  or  lum- 
bricoids,  appendicitis,  urethral  polypus  in  girls,  tumor  of  the  blad- 
der. Digital  examination  should  be  made  per  rectum.  A  stone 
of  considerable  size  may  sometimes  be  felt  distinctly,  but  in  other 
cases  even  when  present  it  cannot  be  detected  by  this  method.  With 
the  patient  anesthetized  and  one  hand  upon  the  pelvis  pressing  the 
bladder  down  upon  the  finger  in  the  rectum,  one  may  succeed  bet- 
ter. A  more  certain  method  is  to  explore  the  bladder  with  the 
sound.  It  should  be  remembered  that  the  curve  in  the  urethra 
behind  the  triangular  ligament  is  more  acute  in  the  child,  and  the 
sound  must  not  only  be  of  a  thickness  appropriate  for  the  caliber  of 
the  urethra,  but  must  have  the  short  curve.    Anesthesia  is  necessary 


672  SURGICAL   DISEASES    OF   CHILDREN 

for  satisfactory  sounding ;  though  occasionally  in  girls  one  may 
succeed  without  it.  One  should  not  be  deceived  by  the  touch  of  a 
very  hard  tumor,  or  of  the  rugous  lining  of  a  bladder  irritated  and 
contracted,  which  may  be  mistaken  for  a  stone;  nor,  on  the  other 
hand,  of  a  stone  coated  with  mucous  deposit  or  blood  clot  in  a  case 
associated  with  cystitis.  But  the  stone  if  present  is  much  more 
likely  to  be  struck  at  once  on  entering  the  sound  into  a  child's  blad- 
der than  would  be  the  case  in  an  adult  patient.  The  conclusion 
may  be  affirmed  or  denied  by  examination  with  the  X-ray,  or  better 
by  an  Xradiograph. 

Prognosis. — A  small  stone  may  be  fortunately  passed  per  ure- 
thram,  but  such  a  lucky  event  is  by  no  means  to  be  waited  for. 
There  is  no  probability  of  cure  by  medical  treatment.  If  not  re- 
moved by  surgical  means,  further  results  will  probably  develop. 
For  instance,  there  may  be  cystitis,  nephritis,  or  pyelitis,  sometimes 
dilatation  of  ureters,  and  of  the  kidney  pelvis,  hydronephrosis  or 
pyonephrosis.  These,  if  already  present,  may  subside  if  the  stone  is 
removed  from  the  bladder,  and  yet,  as  Erichsen  remarks,  and  Wright 
confirms  the  observation,  although  the  mortality  from  lithotomy  is 
small,  one  seldom  sees  an  adult  who  has  been  cut  for  stone  in  child- 
hood. If  the  condition  be  more  promptly  detected  and  the  stone 
removed  before  secondary  changes  in  the  organs  have  been  pro- 
duced, the  prognosis,  not  only  for  immediate  results,  but  for  a  long 
life,  will  be  greatly  improved. 

Treatment. — The  curative  treatment  of  stone  in  the  bladder  is 
surgical.  Yet  the  surgeon  should  be  acquainted  with  the  means  of 
palliating  the  case  and  putting  the  organs  involved  in  condition  for 
operation.  The  greatest  point  in  palliation  is  to  administer  large 
quantities  of  pure  water, — often  distilled  water  is  preferable.  Be- 
fore using  mineral  waters  or  drugs  the  urine  should  be  carefully 
examined.  If  it  is  acid,  alkaline  water,  such  as  Vichy  or  lithia 
waters,  is  useful.  If  the  urine  is  found  to  be  alkaline,  alkalies  are 
contra-indicated.  In  the  great  majority  of  cases  the  urine  is  acid, 
and  such  remedies  as  potassium  acetate  or  citrate  and,  if  pus  is 
present,  urotropin,  are  indicated.  Infants  will  live  mostly  upon  milk 
and  cream  and  gruel  mixtures.  Children  will  do  best  on  a  diet  of 
vegetables  and  fruits,  with  fish  and  some  fats,  proteids  used  moder- 
ately, and  carbohydrates  guardedly. 

In  the  operative  treatment  of  stone  one  can  well  recall  the  time 
when  all  the  discussion  was  upon  the  relative  merits  of  median  and 
lateral  lithotomy,  and  the  lateral  operation  was  proven  the  prefer- 
able operation  in  boys.  The  greater  difficulty  of  lithotomy  in  boys 
is  chiefly  on  account  of  the  small  size  and  undeveloped  condition 
of  the  parts.  Also  because  the  bladder  in  the  child  is  rather  an 
abdominal  than  a  pelvic  organ,  and  is  somewhat  narrow  and  pointed 


THE   GENITO-URINARY   ORGANS  (^iz 

at  its  lower  end,  so  that  there  is  danger  of  not  opening  fairly  and 
freely  into  the  bladder  but  of  pushing  it  upward,  loosening  it  from 
its  attachments,  dissecting  between  the  bladder  and  the  rectum,  or 
even  tearing  the  urethra  across  near  the  neck  of  the  bladder.  The 
prostate  is  so  small  that  it  is  necessarily  cut  entirely  through ;  and 
the  tissues  of  the  child  are  so  delicate  that  unless  extreme  care  is 
used  extensive  traumatism  and  resulting  sterility  will  result  from 
the  operation.  There  is  the  advantage  in  operating  upon  the  child 
that  a  finger  in  the  rectum  or  a  hand  over  the  pubes  can  reach  the 
bladder  and  aid  in  bringing  the  stone  into  the  grasp  of  the  forceps. 
In  1878  Bigelow  introduced  litholapaxy,  which  after  some  years 
became  established  as  the  operation  of  choice  among  those  skilled  in 
its  use.  The  object  is  to  crush  the  stone  and  to  wash  out  every  par- 
ticle of  it  at  one  sitting.  It  is  scarcely  necessary  to  mention  that 
anesthesia  and  asepsis  are  indispensable.  The  child,  anesthetized 
and  surrounded  by  artificial  heat,  is  placed  in  the  Trendelenberg 
position.  Thus  the  stone  gravitates  to  the  upper  and  back  part  of 
the  bladder  away  from  the  more  vascular  region  near  the  neck. 
The  urine  is  withdrawn  by  catheter  and  then  four  to  six  ounces  of 
saturated  solution  of  boracic  acid  at  the  temperature  of  the  body  is 
injected  to  distend  the  bladder.  The  largest  lithotrite  that  will  pass 
through  the  urethra  without  force  should  be  used.  It  is  well  to 
split  the  meatus  urinarius  to  the  fossa  navicularis  in  order  to  insert 
as  large  an  instrument  as  possible.  It  is  passed  to  the  upper  and 
back  part  of  the  bladder.  The  male  blade  is  partly  withdrawn. 
which  opens  the  jaws  of  the  instrument.  Its  beak  is  then  turned 
and  the  stone  seized.  The  instrument  is  moved  from  side  to  side 
to  make  sure  the  mucous  lining  is  not  also  caught  with  the  stone. 
The  cylindrical  handle  is  now  held  firmly  in  the  left  hand  while  the 
screw  is  turned,  closing  the  jaws  and  crushing  the  stone.  This  ma- 
neuver is  repeated  until  the  entire  calculus  is  reduced  to  sand.  The 
lithotrite  is  closed  and  opened  and  closed  again  empty  to  prevent 
any  spicules  of  stone  from  being  held  in  its  jaws  during  its  with- 
drawal, thus  lacerating  the  urethra.  It  is  now  withdrawn  and  the 
special  catheter  introduced.  The  wash-bottle,  containing  a  few 
ounces  of  warm  boracic  solution,  is  now  attached  to  the  catheter  and 
by  compression  and  relaxation  of  the  rubber  bulb  attached  to  the 
bottle  the  solution,  and  with  it  the  sand,  is  withdrawn  from  the  blad- 
der. The  sand  falls  into  the  bulb  below  and  does  not  return  into  the 
bladder.  This  washing  is  continued  tmtil  every  particle  of  the 
crushed  calculus  has  been  removed.  The  necessity  for  this  is  not 
only  the  irritation  that  would  be  caused  by  its  remaining,  but  be- 
cause it  might  serve  for  the  beginning  of  another  calculus.  With 
litholapaxy  there  is  some  danger  of  injuring,  even  rupturing,  the 
bladder  or  of  rupturing  or  excoriating  the  urethra ;  but  a  more  f  re- 


674  SURGICAL   DISEASES    OF   CHILDREN 

quent  error  is,  to  fail  to  remove  all  the  fragments.  Before  finally 
removing  the  catheter  the  surgeon  should  auscultate  over  the  blad- 
der while  washing  to  detect  the  click  of  a  fragment  against  the  cathe- 
ter. The  entire  operation  may  take  an  hour,  less  or  more,  and  occa- 
sions some  shock ;  but  as  there  is  no  blood  loss  this  is  soon  recovered 
from.  There  is  no  darriage  to  the  reproductive  apparatus  as  in 
perineal  lithotomy.  A  possible  source  of  failure  in  the  operation  of 
litholapaxy  is  inability  to  crush  an  exceedingly  hard  stone.  In  such 
a  predicament  the  surgeon  should  immediately  perform  suprapubic 
lithotomy. 

Suprapubic  lithotomy  is  not  merely  a  last  resort  in  case  of 
failure  to  execute  litholapaxy.  It  is  preferred  to  litholapaxy  by 
many  surgeons  unless  the  stone  is  very  small,  and  to  lateral  lithot- 
omy by  many  more.  It  occasions  no  damage  to  prostate,  urethra 
or  ejaculatory  ducts,  and  no  possibility  of  injury  to  the  rectum. 
The  danger  of  damage  to  the  peritoneum  is  not  feared  since  anti- 
septic surgery  is  well  understood.  Infection  of  the  prevesical  space 
or  infiltration  with  urine  can  be  avoided  by  careful  management  of 
the  drainage.  If  the  urine  is  known  to  be  foul,  suprapubic  cystotomy 
may  be  done  in  two  stages,  as  recommended  by  Senn.  By  this  plan 
the  incision  is  made  down  to  the  bladder,  which  is  exposed  but  not 
opened  in  the  first  stage,  and  several  days  allowed  to  elapse  during 
which  granulations  form  under  gauze  dressings  and  effectually  seal 
off  the  preivesical  cellular  and  fatty  tissues.  Then  under  local  co- 
caine anesthesia  the  bladder  is  opened.  If  desired  the  same  method 
can  be  used  in  the  ordinary  case.  But  the  ordinary  case  in  a  child 
is  not  complicated  with  a  chronic  cystitis.  The  suprapubic  operation 
is  well  adapted  to  children  also,  because  with  them  the  bladder  pro- 
jects higher  above  the  os  pubis  than  in  the  adult,  and  can  be  entered 
without  going  too  close  above  or  behind  the  bone.  The  operation 
is  more  easily  performed  by  the  general  surgeon  who  has  not  had 
frequent  occasion  to  remove  vesical  calculus  and  become  familiar 
with  either  lithotomy  or  litholapaxy.  It  can  be  done  under  the  eye 
without  cutting  in  the  dark,  and  the  bladder  can.  if  necessary,  be 
inspected. 

The  operation  is  performed  as  follows:  The  child's  rectum 
has  been  emptied  by  enema.  He  is  anesthetized,  placed  in  the  Tren- 
delenberg  position,  surrounded  by  artificial  heat.  It  is  not  necessary 
to  distend  the  rectum  by  a  water  or  air  bag.  The  skin  is  cleansed 
as  if  for  an  abdominal  section.  The  bladder  is  emptied  by  a  sterile 
catheter,  and  then  three  to  six  ounces  of  warm  boracic  solution  are 
injected  so  as  to  fill  the  bladder  moderately.  This  is  held  in  by  gen- 
tle compression  upon  the  urethra  at  the  root  of  the  penis  by  a  com- 
press and  bandage.  An  incision  through  the  skin  is  made,  beginning 
on  the  upper  edge  of  the  center  of  the  symphisis  pubis  and  extend- 


THE    GENITO-URINARY    ORGANS  675 

ing  upward  in  the  middle  line  a  distance  of  two  inches.  The  dissec- 
tion is  carried  down  gradually  between  the  recti  muscles  and  pre- 
vesical fat  until  the  bladder  is  reached  and  laid  bare.  The  bladder 
can  generally  be  readily  recognized  by  its  thickness  and  greater  vas- 
cularity and  its  muscular  fibers.  Some  surgeons,  after  injecting  the 
boracic  acid,  tie  the  catheter  in,  so  that  by  pressing  its  end  upward 
toward  the  incision  the  bladder  wall  may  be  verified.  When  a  small 
ellipse  of  the  bladder  is  laid  bare,  two  silk  sutures  are  introduced 
(without  penetrating  the  mucous  lining),  one  at  the  upper  and  one 
at  the  lower  angle  of  the  incision,  so  that  when  the  bladder  is  in- 
cised between  them  the  sutures  can  be  used  as  retractors,  being 
much  more  convenient  than  forceps  for  that  purpose.  The  bladder 
having  been  steadied  by  drawing  upon  the  sutures,  and  opened  with 
the  scalpel,  a  finger  is  introduced  and  finds  the  stone,  which  is  re- 
moved with  forceps.  The  wound  in  the  bladder  is  then  closed  with 
Lembert  sutures.  Some  operators  close  the  external  wound  also  at 
once.  Others  prefer  to  leave  it  to  granulate.  If  the  wound  is  clean, 
with  no  cystitis,  there  can  be  no  objection  to  closing  it  at  once.  The 
bladder  should  be  kept  empty  by  catheter. 

With  stone  in  the  bladder  of  a  girl,  anesthesia  should  be  in- 
duced, the  urethra  rapidly  dilated  and  the  stone  removed  by  forceps 
or  crushed  and  washed  out.  If  it  is  too  large  or  too  hard  for  this 
method,  suprapubic  cystotomy  should  be  done, 

CALCULUS     IN    THE    URETHRA,    FOREIGN     BODY     IN     THE 
URETHRA  OR  IN  THE  BLADDER  (52) 

A  case  may  present  symptoms  of  stone  in  the  bladder  or 
of  obstruction  to  the  flow  of  urine,  and  on  attempting  to  pass  the 
catheter  or  to  sound  the  bladder  the  surgeon  may  find  the  urethra 
blocked  by  a  calculus,  or,  in  rare  instances,  by  a  foreign  body 
placed  there  by  the  child  himself  or  herself,  or  by  mischievous 
companions  or  by  accident.  One  has  known  a  soft  catheter  to  go 
adrift  from  the  fingers  of  an  unlucky  young  doctor.  A  small 
calculus  is  apt  to  lodge  at  the  fossa  navicularis,  or  at  some  point 
higher  up.  If  the  stone  or  the  foreign  body  cannot  be  removed 
by  seizing  it  with  slender  forceps  or  drawing  it  out  with  a  tiny 
scoop  fashioned  upon  the  flat  end  of  a  probe,  it  is  necessary  to 
incise  the  urethra  upon  the  obstruction  and  remove  it.  Otherwise 
the  blocking  of  the  urethra  would  result  in  inflammation  and 
probably  sloughing  of  the  urethra  at  that  point,  besides  serious 
damage  from  retention  of  the  urine.  But  incision  of  the  urethra 
is  not  to  be  too  lightly  resorted  to,  for  although  the  wound  be 
afterward  carefully  sutured,  penile  fistula  may  result  or  the  cica- 
trix contract  the  urethra  at  that  point. 

If  a  foreign  body  has  found  its  way  into  the  bladder  it  will 


676  SURGICAL    DISEASES    OF    CHILDREN 

have  to  be  removed.  In  a  girl,  if  the  body  is  round  like  a  bead  it 
may  sometimes  be  washed  out  by  flushing  the  bladder  with  warm 
boracic  acid  or  normal  salt  solution;  or  this  plan  may  succeed 
after  dilating  the  urethra.  Or,  after  urethral  dilatation,  the  body 
may  be  seized  with  forceps  and  extracted.  One  has  had  occasion 
to  remove  thus,  a  cotton  wad  in  one  case,  and  a  pencil  made  of 
chewing  gum  in  another.  In  a  boy  suprapubic  cystotomy  may  be 
required. 

RUPTURE  OF  THE  URETHRA 

Occasionally  the  urethra  of  a  boy  is  ruptured  _either  in  its 
membranes  or  its  spongy  portion  by  falling  astride  of  a  fence 
or  the  like.  This  occasions  pain  and  swelling  of  the  part,  bloody 
urine,  and,  by  and  by,  retention  of  urine.  Later,  extravasation 
of  urine  may  occur  with  serious  local  and  general  consequences, 
unless  the  part  is  freely  incised  and  drained.  Immediately  after 
the  accident  a  careful  attempt  should  be  made  to  pass  a  catheter. 
If  successful,  the  catheter  should  be  tied  in  and  kept  there  for 
several  days  and  then  changed.  It  will  probably  be  necessary  to 
pass  instruments  at  intervals  for  years  if  not' for  life.  Ashby  and 
Wright  recommend  in  rupture  of  the  urethra  to  cut  down  im- 
mediately and  unite  the  torn  structure  with  fine  sutures.  I  have 
once  met  also  a  torn  urethra  in  a  girl,  who  fell  from  a  table,  astride 
of  a  broken  chair.    Immediate  suture  resulted  in  perfect  repair. 

EPISPADIAS 

Epispadias  is  that  condition  of  the  penis  which  has  been  de- 
scribed in  the  Section  on  Extroversion  of  the  Bladder.  The 
urethra  is  merely  an  open  gutter  or  groove  along  the  dorsum  of 
the  penis.  It  may  be  present  without  extroversion  or  any  other 
malformation  of  the  bladder ;  but  there  is  apt  to  be  associated 
with  it  malformation  of  the  pubic  symphysis,  which  is  joined  only 
by  ligamentous  union.  A  small  bladder  with  deficient  muscular 
control  has  also  been  found  in  connection  with  it,  the  patient 
not  being  able  to  retain  the  urine  when  standing.  (Partridge, 
Holmes.)  Sexual  incompetence  and  sterility  are  usual  with  these 
patients ;  yet  one  should  not  too  hastily  consider  them  all  incom- 
petent or  sterile,  without  ascertaining  the  peculiarities  of  each  case. 

Epispadias  is  not  a  very  common  deformity,  which  is  for- 
tunate, for  it  is  not  easily  nor  satisfactorily  remedied  by  surgery. 

Treatment. — Treatment  is  by  plastic  operation.  The  older 
methods  consisted  of  taking  a  skin  flap  from  the  abdomen,  groin 
or  scrotum.  That  described  by  Holmes,  who  got  the  idea  from 
Follin,  is  a  representative  of  this  plan  of  operation.  A  flap  may  be 
made  e>.  tending  longitudinally  upward  on  the  abdomen  with  its 
hinge  at  the  root  of  the  penis,  as  in  Segond's  operation  for  hiatus 


THE    GENITO-URINARV    ORGANS  t^^ 

of  the  bladder.  It  should  be  made  of  ample  size  to  allow  for 
contraction.  The  edges  of  the  urethral  gutter  are  then  freshened. 
The  flap  is  then  turned  down  with  its  epidermal  side  toward  the 
penis  and  its  raw  side  up,  and  attached  to  the  freshened  margins 
of  the  gutter.  The  scrotum  is  then  incised  transversely  in  two 
places,  one  incision  at  the  peno-scrotal  junction  and  the  other  at 
a  little  distance  farther  back  (or  down).  The  skin  of  the  scrotum 
between  these  two  incisions  is  lifted  up,  which  makes  a  bridge-flap 
attached  at  both  ends.  This  flap  is  brought  over  the  penis  with  its 
raw  lower  surface  opposed  to  the  raw  upper  surface  of  the  newly 
placed  skin-flap.  The  plan  is  varied  in  many  ways  to  suit  the 
individual  case.  But  all  such  methods  have  the  great  disadvantage 
of  placing  epidermal  surface  within  the  urethra,  so  that  later  the 
growth  of  hair  is  very  troublesome.  To  turn  the  raw  surface  of 
a  skin-flap  inward  is  less  objectionable  even  with  the  contraction 
which  is  sure  to  result.  To  secure  suitable  material  for  the  con- 
struction of  the  urethra  has  led  to  many  devices  very  ingenious 
in  plan,  all  more  or  less  difficult  of  execution  upon  a  small  field, 
and  some  of  them  dependent  for  success  upon  so  many  fortunate 
contingencies  as  to  be  impracticable  for  the  general  run  of  cases. 

Thiersch's  operation  is  one  of  the  less  complicated.  It  is  per- 
formed in  three  stages  as  follows :  First,  for  the  formation  of  the 
urethra  in  the  glans,  an  incision  is  made  in  the  glans  longitudinally 
at  each  side  of  the  urethral  gutter.  A  glass  or  metal  rod  is  laid 
in  the  gutter  or  groove,  and  the  lateral  portions  of  the  glans, 
that  is,  the  parts  to  the  outer  edges  of  the  incisions,  are  brought  up 
over  the  rod,  and  their  raw  edges  are  sutured  together  with  quill 
sutures.  Thus  the  rod  occupies  the  position  of  the  new  urethra. 
When  this  portion  has  completely  healed  and  the  urethra  is  estab- 
lished in  the  glans  the  next  step  is  the  construction  of  the  penile 
portion  of  the  urethra. 

For  this  purpose  two  flaps  are  made  longitudinally  upon  the 
lateral  aspects  of  the  penis.  (See  Fig.  233,  I,  II;  and  III.)  For 
instance,  Flap  A  has  an  incision  at  the  left  side  of  the  penis  and 
i'ts  hinge  at  the  left  margin  of  the  urethral  gutter.  Flap  B  has 
its  incision  at  the  right  margin  of  the  urethral  gutter  and  its  hinge 
on  the  right  lateral  aspect  of  the  penis.  Flap  A  is  now  turned 
back  so  that  its  skin  surface  covers  in  the  urethra  while  its  raw 
surface  is  outward,  and  is  sutured  in  that  position.  Flap  B  is 
now  slid  directly  across  and  sutured  so  that  its  under  or  raw  sur- 
face lies  upon  the  raw  surface  of  Flap  A  while  its  skin  surface 
forms  the  dorsal  surface  of  the  new  urethra.  There  still  remain 
two  openings,  one  between  the  balanic  and  the  penile  portions  of 
the  new  urethra  and  another  at  the  base  of  the  penis.  To  close 
the   first   opening   its    margins    are    freshened    and   the   prepuce    is 


678 


SURGICAL  DISEASES    OF   CHILDREN 


utilized.  The  prepuce  in  epispadias  is  incomplete  dorsally,  but 
somewhat  voluminous  as  it  hangs  from  the  under  surface.  This 
prepuce  is  buttonholed  by  a  transverse  incision  and  the  glans 
slipped  through  the  opening.  This  brings  the  prepuce  on  the 
upper  side  with  its  raw  surface  applied  to  the  freshened  margins  of 


M    m 


Fig.  233.    I,  II  and  III — Thiersch's  operation  for  epispadias.    IV — ^Duplay's 

OPERATION     FOR     HYPOSPADIAS. 

the  gap  in  the  urethra,  and  is  there  sutured  in  position.  The 
defect  remaining  at  the  base  of  the  penis  is  closed  by  turning  a 
small  flap  of  skin  from  the  pubes. 


HYPOSPADIAS 

Hypospadias  occurs  much  more  frequently  than  epispadias. 
In  the  process  of  development  by  which  the  male  urethra  is 
formed,  a  groove  appears  extending  from  the  uro-genital  sinus 
forward  along  the  perineum  and  the  under  surface  of  the  penis 
to  the  end  of  the  glans.  Then  the  margins  of  this  groove  arch 
over  and  join,  thus  forming  a  canal,  the  closure  taking  place  from 
behind  forward.  If  this  closure  fails  to  take  place  there  is  pres- 
ent this  condition  called  hypospadias.  The  arrest  of  development 
may  take  place  at  any  stage — when  the  closure  has  gotten  no 
farther  than  the  perineo-scrotal  region,  or  more  frequently  when 
it  has  proceeded  to  a  point  somewhere  in  the  penile  portion,  or, 


THE    GENITO-URINARY    ORGANS  679 

commonest  of  all,  the  canal  may  end,  very  likely  in  a  pinhole  ori- 
fice or  a  tiny  slit  underneath  the  glans.  In  these  cases  the  prepuce 
may  be  normal,  but  is  usually  deficient  on  the  under  surface  and 
gathered  like  a  voluminous  hood  upon  the  dorsal  aspect.  Hypo- 
spadias in  its  more  severe  forms  is  apt  to  be  associated  with  adhe- 
sions between  the  under  surface  of  the  penis  and  the  scrotum  by 
which  the  penis  is  tied  down  by  fibrous  tissues  covered  with  integ- 
uments. Another  malformation  of  the  urethra  is  its  closure  by 
a  membranous  septum  at  its  distal  end  while  it  has  an  opening 
in  the  penile  or  perineal  regions. 

Treatment. — When  the  incomplete  urethra  terminates  some- 
where near  the  distal  end  of  the  penis  it  is  not  really  necessary  to 
do  anything  for  its  extension.  But  if  it  is  thought  desirable  to  com- 
plete the  canal  it  can  be  done.  There  are  a  number  of  operations 
for  this  purpose. 

Beck's  operation  is  by  dissecting  up  a  portion  of  the  urethra 
and  stretching  it  forward  and  transplanting  it  into  the  urethral 
groove  on  the  under  side  of  the  glans,  which  has  been  freshened 
to  receive  it.  In  case  there  is  no  groove  or  gutter  which  can  be 
utilized,  Ochsner  and  others  have  perforated  the  glans  and  pulled 
the  mobilized  urethra  through  this  perforation  and  sutured  it 
there.  Or  the  redundant  prepuce  can  be  used  as  a  flap.  By  this 
method  an  incision  is  made  transversely  across  the  prepuce  and 
the  glans  thrust  through  this.  This  maneuver  brings  the  bridge 
of  skin  upon  the  under  side,  the  surface  of  which  has  been  prop- 
erly denuded  for  apposition  with  the  raw  surface  of  the  flap.  The 
flap  is  then  sutured  in  position. 

When  the  urethral  orifice  is  closed  by  membrane  it  will  re- 
quire opening;  and  when  diminutive  it  will  need  dilating,  some- 
times quite  persistently.  A  small  gap  in  the  perineal  or  penile 
urethra  may  be  closed  by  a  small  skin  flap  carried  over;  but  the 
lack  of  a  large  portion  of  the  urethra  or  the  tied-down  condition 
of  the  penis  will  necessitate  a  considerable  amount  of  work  for 
their  correction. 

Thiersch's  operation  as  described  for  epispadias  may  some- 
times be  adapted  to  hypospadias. 

When  the  penis  is  curved  downward  and  held  by  adhesions 
it  must  first  be  set  free  and  straightened.  Duplay  does  this  by 
dividing  the  fibrous  bands  transversely.  This  can  be  done  sub- 
cutaneously.  But  often  the  skin  also  is  at  fault,  and  it  is  better 
to  divide  both  the  skin  and  the  fibrous  adhesions.  Several  such 
incisions  may  be  necessary.  The  penis  is  then  stretched  upward, 
which  renders  the  transverse  incisions  longitudinal,  and  they  are 
sutured  in  that  position.  The  penis  is  dressed  in  a  straight  posi- 
ton  strapped  up  against  the  abdominal  wall   during  the  process 


68o  SURGICAL  DISEASES   OF   CHILDREN 

of  healing.  After  the  organ  has  been  thoroughly  straightened,  or 
in  cases  in  which  it  was  not  bound  down,  one  may  proceed  at  once 
to  the  formation  of  the  urethra.  This  begins  with  the  glans,  for 
which  Thiersch's  operation  for  epispadias  may  be  adapted.  After 
the  balanic  urethra  has  been  established  comes  the  task  of  con- 
structing the  penile  portion.  To  avoid  the  continual  soiling  of 
the  field  of  operation  and  the  wound,  it  is  often  best  to  establish 
perineal  drainage.  C.  H.  Mayo  advises  the  use  of  a  Jacobs  self- 
retaining  female  catheter  introduced  through  the  perineal  wound. 
C.  H.  Mayo  and  Van  Hook  each  have  a  very  ingenious  opera- 
tion. Or  Duplay's  operation,  or  some  modification  of  it,  may  be 
employed.  (See  Fig.  233,  IV.)  Two  longitudinal  incisions  are 
made,  one  at  each  side  of  the  urethral  gutter,  parallel  with  it  and 
about  three-eighths  of  an  inch  from  it.  Transverse  incisions  are 
made  at  the  ends  of  these,  and  long,  narrow  flaps  are  dissected  up 
with  their  hinges  at  the  margins  of  the  urethral  gutter.  Two 
other  skin  flaps,  one  at  each  side,  are  formed  by  dissecting  back 
from  the  first  incisions.  A  glass  or- metal  rod  is  now  laid  in  the 
urethral  groove  or  gutter  and  the  first  two  flaps  are  turned  up 
over  it  with  their  skin  surfaces  inward  toward  the  rod  and  their 
raw  surfaces  outward.  They  should  not  be  so  wide  that  their 
margins  meet  over  the  rod.  The  two  lateral  flaps  should  now  be 
slid  up  over  these  and  attached  in  the  middle  line  with  quill  sutures 
or  lead  button  sutures,  with  the  raw  surfaces  partly  in  contact 
along  the  middle  line  and  apposed  to  the  raw  surfaces  of  the  two 
first  flaps  which  are  lying  over  the  rod. 


ADHERENT  PREPUCE 

In  fetal  life  the  mucous  lining  of  the  prepuce  is  normally 
adherent  to  the  glans,  and  this  condition  frequently  lingers  at 
birth.  Occasionally  continued  development  after  birth  soon  frees 
the  adhesion,  but  quite  as  frequently  if  neglected  it  becomes 
stronger.  It  may  give  rise  to  many  of  the  symptoms  caused  by 
phimosis,  but  the  most  frequent  are  retention  of  segma,  and  bala- 
nitis. It  should  receive  attention  in  every  instance  without  wait- 
ing for  symptoms.  The  prepuce  should  be  retracted  by  force, 
using  a  probe  or  grooved  director  as  a  blunt  dissector  if  neces- 
sary to  separate  membrane  from  glans.  The  smegma  is  washed 
away,  the  part  dried  and  lubricated  with  sterile  olive  oil  carbolized 
one  per  cent.,  or  with  sterilized  vaselin,e,  and  the  prepuce  drawn 
forward.  The  part  should  be  cleaned  daily  and  dressed  in  the 
same  manner  until  each  raw  surface  is  healed  soundly  and  sepa- 
rately, and  should  be  cleansed  daily  thereafter  at  the  bath. 


THE    GENITO-URINARY   ORGANS  68i 

PHIMOSIS 

Phimosis  is  a  malformation  in  which  the  prepuce  is  too  tight 
to  be  retracted  upon  the  glans  penis.  The  tight  foreskin  may  or 
may  not  be  redundant  at  the  end ;  and  its  mucous  hning  may  or 
may  not  be  adherent  to  the  glans.  The  orifice  may  be  occluded 
or  small;  or  far  more  frequently,  even  in  the  cases  of  redundant 
prepuce,  there  is  a  sufficient  opening  for  passage  of  urine.  Every 
case  of  phimosis  needs  attention.  I  am  not  one  of  those  who  at- 
tribute all  the  ills  of  the  flesh  to  phimosis,  yet  am  quite  certain 
it  is  capable  of  giving  rise  to  one  or  more  of  a  troublesome  list 
of  symptoms  and  conditions.  The  effects  of  phimosis  may  result 
directly  through  mechanical  obstruction  to  the  outflow  of  urine; 
such  as  painful  urination  and  retention  of  urine.  Later  this  may 
be  so  extreme  as  to  cause  dilatation  of  the  ureters  and  the  kidney 
pelves,  with  the  degeneration  of  the  kidney  structure  that  follows 
blocking  of  the  urinary  canal  at  any  point.  Hernia,  either  inguinal 
or  umbilical,  may  be  caused  and  perpetuated  by  straining  during 
micturition.  Prolapsus  ani  sometimes  results  from  the  same 
cause.  Other  effects  are  produced  reflexly  through  the  nervous 
system.  For  example,  retention  of  urine  from  vesical  spasm,  in- 
continence from  irritation,  muscular  spasm  in  a  lower  extremity 
causing  a  limp  simulating  early  hip-joint  disease,  extreme  nerv- 
ousness and  irritability,  constipation  from  reflex  inhibition,  in- 
somnia or  night  terrors.  With  this  last-mentioned  symptom  the 
boy  is  in  the  act  of  falling  asleep  when  an  erection  occurs  produc- 
ing pain  from  tension  upon  adhesions,  or  irritation  which  causes 
him  to  wake  with  a  startled  cry ;  when  he  settles  back  to  sleep 
again  the  same  performance  is  repeated,  and  he  becomes  worn 
and  nervous.     Or  the  priapism  leads  to  masturbation. 

Chorea,  epilepsy,  amaurosis  or  strabismus  I  have  never  met 
as  reflex  effects  of  phimosis.  Another  group  of  results  come 
about  by  retention  of  smegma  preputialis  and  interference  with 
cleanliness.  Smegma  may  be  accumulated  in  masses  of  the  size  of 
lentils  or  larger  masses  beneath  the  prepuce,  usually  behind  the 
corona.  One  has  seen  a  collection  of  the  size  of  a  navy  bean 
embedded  in  the  glans  which  was  correspondingly  misshapen.  Re- 
tained secretion  seldom  gives  rise  to  malformation,  but  often  to 
irritation,  and,  becoming  infected,  causes  inflammation.  Thus 
balanitis  is  a  common  consequence  of  phimosis ;  and  occasionally 
leads  to  urethritis  and  cystitis. 

Treatment. — The  best  time  for  treatment  is  in  infancy.  With 
the  exception  of  those  unusual  cases  in  which  the  flow  of  urine  is 
entirely    or    almost    entirely    prevented,    treatment    may    be    post- 


e&2  SURGICAL   DISEASES    OF   CHILDREN 

poned  until  the  umbilicus  has  healed,  or  even  for  a  month  or  two; 
but  there  is  no  advantage  in  waiting  longer;  and  there  is  great 
disadvantage  in  waiting  until  the  boy  runs  about  and  is  difficult 
to  restrain  during  the  healing  process  following  operation;  or 
until  balanitis  has  occurred,  perhaps  with  retention,  and  one  is 
obliged  to  cut  through  the  swollen  and  infected  prepuce  in  order 
to  cleanse  beneath  it.  A  slight  degree,  but  only  a  very  slight  degree, 
of  phimosis  should  be  treated  by  stretching.  Even  some  cases 
that  might  be  stretched  are  better  treated  if  the  prepuce  is  re- 
dundant, by  circumcision.  When  repeated  stretchings  are  neces- 
sary it  is  far  better  to  circumcise.  The  prepuce  should  not  only 
be  retractable,  but  it  should  retract  freely,  and  it  should  easily 
fall  forward  again  without  constriction,  lest  paraphimosis  occur,  and 
this  looseness  should  be  secured  without  the  numerous  manipu- 
lations of  repeated  stretchings  and  oilings  that  some  advise.  The 
better  plan  is  circumcision  or  a  modification  of  that  operation. 
It  is  not  invariably  necessary  to  remove  a  part  of  the  prepuce. 
Sometimes  it  is  sufficient  to  insert  a  grooved  director  beneath  the 
mucous  lining  of  the  prepuce,  move  the  instrument  all  about  until 
the  adhesions  are  freed,  then  split  up  the  prepuce  upon  the  director 
so  as  to  expose  the  glans  almost  to  the  corona.  The  corners  left 
in  front  by  the  incision  may  then  be  rounded  off  if  necessary 
and  a  stitch  or  two  be  taken  at  ,each  side  to  unite  the  mucous 
lining  and  skin. 

Circumcision  is  a  small  operation,  yet  it  is  worth  doing  neatly 
and  surgically.  In  very  young  infants  an  anesthetic  is  not  neces- 
sary; but  from  six  months  or  a  year  and  upwards  anesthesia 
should  be  used.  The  part  should  be  cleansed  with  soap  and  water 
and  then  by  an  antiseptic  solution. 

It  is  a  great  convenience  to  use  a  small  rubber  band  as  an 
Esmarch  around  the  root  of  the  penis.  The  redundant  prepuce  is 
then  drawn  forward  with  forceps,  taking  care  not  to  draw  much 
more  upon  its  skin  than  upon  its  mucous  lining.  It  is  then  seized 
just  in  front  of  the  glans  with  a  pair  of  thin  bladed  forceps  or 
the  like,  and  cut  off  in  front  of  that  instrument,  which  protects 
the  glans  from  injury.  The  prepuce  is  then  released  and  immedi- 
ately retracts  some  distance  upon  the  glans,  usually  farther  than 
the  mucous  membrane,  especially  if  the  latter  is  adherent.  The 
amount  of  prepuce  that  should  be  removed  is  a  matter  of  judg- 
ment. There  should  always  be  enough  left  to  cover  the  corona 
glandis  when  the  operation  is  completed,  and  one  aims  to  have  it 
of  sufficient  length  to  expose  but  half  of  the  glans.  The  mucous 
lining  of  the  prepuce  is  now  loosened  from  the  glans  by  passing 
under  it  a  grooved  director,  and,  together  with  the  skin  split  up  to 
the  proper  distance,  taking  care  not  to  incise  the  meatus  at  the 
same  time.     The  corners  thus  made  are   rounded  with   scissors ; 


THE    GENITO-URINARY    ORGANS  683 

and  any  redundance  near  the  frenum  may  be  trimmed  off.  The 
cut  margins  of  the  mucous  membrane  and  skin  are  united  by  in- 
terrupted sutures  of  fine  catgut,  first  placing  one  at  the  angle  of 
the  dorsal  incision  and  one  at  the  frenum  including  the  artery.  It 
is  worth  while  to  suture  each  third  of  an  inch.  The  Esmarch  is 
then  snipped  open  with  scissors.  If  one  or  two  points  bleed  they  may 
be  conveniently  caught  by  an  extra  suture.  After  trying  many 
dressings  for  circumcision  I  long  ago  found  sterilized  olive  oil 
phenolated  i  per  cent.,  the  most  comfortable  and  satisfactory. 
Gauzes,  collodion  and  the  rest  are  all  uncomfortable  or  stick  to 
the  wound,  or  become  urine  soaked.  A  narrow  strip,  a  foot  or 
more  long,  of  absorbent  cotton  should  be  torn  off  the  layer,  and 
wound  about  the  penis.  The  organ  should  be  thickly  enveloped 
in  the  cotton  from  the  root  to  the  meatus.  A  few  drachms  of  the 
carbolized  oil  are  then  poured  in  upon  the  glans,  and  a  patch  of 
cotton  laid  upon  the  top.  If  the  boy  urinates  the  urine  runs  over 
the  oily  cotton  and  does  not  affect  the  wound ;  the  oil  also  tends 
to  prevent  readhesion  of  the  mucous  membrane  and  glans.  The 
mother  is  directed  to  pour  on  a  drachm  of  the  oil  once  or  twice  a 
day.  Some  cases  are  then  lightly  bandaged  around  the  waist.  If 
the  cotton  stays  in  place  it  is  left  two  days  before  the  first  change. 
The  mother  is  taught  how  to  apply  the  dressing  if  the  child's 
restlessness  displaces  it.  The  fine  catgut  sutures  usually  never  need 
to  be  removed,  as  they  com,e  away  in  a  few  days. 

PARAPHIMOSIS 

In  paraphimosis  a  somewhat  tight  prepuce  has  been  retracted 
behind  the  corona  glandis  and  caused  constriction  interfering  with 
the  circulation  in  the  parts  distal  to  it.  If  unrelieved,  ulceration 
.and  sloughing  would  occur,  sooner  or  later,  according  to  the  degree 
of  the  constriction.  It  is  not  necessary  that  the  constricting  band 
be  extremely  tight  to  cause  edema  and  inflammation.  Fig.  234 
was  photographed  on  the  third  day.  It  shows  a  constriction  only 
moderately  tight,  so  that  for  a  moment  the  inexperienced  might 
doubt  the  nature  of  the  ailment. 

Treatment. — The  glans  must  be  reduced  through  the  con- 
stricting ring  or  band  of  the  tight  prepuce.  An  anesthetic  is 
generally,  though  not  always,  necessary.  The  corona  is  then 
lubricated  with  oil  or  vaseline,  and  the  penis  encircled,  just  be- 
hind the  swelling,  by  the  left  index  finger  and  thumb  of  the  sur- 
geon. The  swollen  glans  is  then  gently  and  persistently  pressed 
backward  by  the  thumb  and  fingers  of  the  right  hand,  while  the 
prepuce  is  pulled  forward  with  the  left,  until,  the  edema  having 
been  lessened,  the  glans  recedes  through  the  constricting  prepuce. 
A  few  minutes'  time  is   usually  sufficient   for  a  reduction.     But 


6§4  SURGICAL  DISEASES    OF   CHILDREN 

the  process  may  be  much  more  difficult  and  tedious.  The  tissue 
may  be  so  stiffened  from  the  sw.elhng  that  reHef  by  this  method 
is  impossible.  In  this  case  the  constriction  must  be  divided  longi- 
tudinally in  the  middle  line  upon  the  dorsum  of  the  organ,  by 
passing  under  it  a  sharp-pointed  curved  bistoury.  A  wet  anti- 
septic dressing  should  then  be  applied.  Following  every  case  of 
paraphimosis,  when  the  swollen  tissues  have  returned  to  the  nor- 
mal condition  a  circumcision  should  be  performed. 

OTHER    CONSTRICTIONS    OF   THE    PENIS. 

Constriction  of  the  penis  by  a  thread  or  string  or  rubber  band, 
wire,  or  metal  ring  is  occasionally  met,  and  the  encircling  body,  if 


Fig.  234.  Paraphimosis.    Only  moderately  tight  constriction     3d  day.    18  mos. 

narrow,  may  so  bury  itself  in  the  swollen  tissues  as  to  be  hidden.  A 
suspicion  of  the  cause  should  be  suggested  by  the  swelling  and  lead 
to  its  discovery  and  division. 

Treatment. — The  removal  of  a  metal  ring  may  be  facilitated 
by  bandaging  the  penis  with  a  narrow  bandage  tightly  and  evenly 
applied  beginning  at  the  distal  end  and  squeezing  back  the  blood 
and  serum,  part  of  which  may  be  allowed  to  escape  through  needle 
wounds.  When  the  size  of  the  penis  has  thus  been  reduced  and  a 
lubricant  used  the  ring  may  be  slipped  off.  I  was  once  obliged  to 
remove  from  a  boy's  penis  a  heavy  steel  ring  by  slipping  diago- 
nally beneath  it  a  fine  saw  such  as  jewelers  use,  and  cutting  out- 
ward. 

DISLOCATION  OF  THE  PENIS 

may  be  produced  by  direct  violence  so  that  it  is  thrust  down- 
ward within  the  scrotum.  It  should  be  restored  to  its  position  by 
careful  manipulation. 


THE    GENITO-URINARY    ORGANS  685 

BALANITIS 

Balanitis  or  inflammation  of  the  prepuce  may  be  due  to  the 
presence  of  the  ordinary  pyogenic  organisms  or  to  the  germs 
of  gonorrhea,  diphtheria  or  erysipelas.  Phimosis  favors  infec- 
tion by  retaining  the  secretions,  which  decompose.  Traumatism 
sometimes  starts  the  trouble.  One  has  seen  it  caused  by  slovenly 
efforts  at  loosening  preputial  adhesions  and  stretching  of  the  fore- 
skin. 

Treatment. — Treatment  is  by  removing  irritating  material 
such  as  smegma  from  beneath  the  prepuce  and  behind  the  corona. 
This  may  sometimes  be  accomplished  by  the  use  of  a  syringe,  and 
solution  of  mercuric  bichloride,  i  to  4000  or  i  to  5000.  Dressings 
wet  with  the  same  solution,  or  with  lead  and  opium  wash,  or 
boric  acid  solution  should  be  constantly  applied. 

In  the  gonorrheal  forms  the  use  of  silver  nitrate  solution  one 
or  two  per  cent.,  or  of  argyrol  solution  10  to  15  per  cent,  once  or 
twice  a  day,  with  mild  lotions  at  short  intervals,  are  efficient.  Ice, 
or  ice  patches  in  the  acute  stages  and  bathing  with  hot  solutions  in 
passive  edema  are  useful.  In  phimosis  it  may  be  necessary  to  split 
open  the  prepuce  in  order  to  cleanse  beneath.  The  circurricision 
should  not  be  completed  during  the  attack  of  inflammation,  but 
subsequently. 

URETHRITIS 

Urethritis  may  occur  independently,  but  is  more  often  asso- 
ciated with  balanitis.  It  may  be  simple  or  gonorrheal.  Simple 
urethritis  seldom  extends  deeper  than  the  fossa  navicularis. 

Symptoms  and  Diagnosis. — The  simple  form  causes  pain  on 
micturition,  and  a  discharge  of  pus,  and  sometimes  gluing  together 
of  the  lips  of  the  meatus  with  the  discharges.  The  gonorrheal 
form  is  more  severe,  extends  deeper  and  is  more  persistent.  In 
fact  it  may  present  the  usual  symptoms  and  complications  of  the 
same  disease  in  the  adult  although  they  differ  in  their  relative 
frequency.  Constitutional  symptoms  and  orchitis  are  less  com- 
mon in  the  boy  than  in  the  man.  Arthritis  occurs,  infrequently, 
but  sometimes  in  a  severe  form.  (See  Section  on  Gonococcus 
Arthritis.)  Conjunctivitis  is  a  far  more  frequent  complication. 
Secondary  lymphadenitis  occurs.  One  should  not  be  surprised 
at  discovering  specific  inflammation  of  the  genito-urinary  organs 
in  very  young  boys  or  even  in  infants,  although  it  is  far  less 
common  than  vulvovaginitis  in  little  girls.  The  detection  of  the 
gonococcus  with  the  microscope  is  the  only  positive  proof  of 
gonorrhea. 

Treatment. — Treatment  is  the  same  as  in  the  adult,  with  the 


686  SURGICAL   DISEASES    OF   CHILDREN 

exception  that  a  great  deal  more  care  is  necessary  to  prevent  the 
infection  from  being  carried  by  the  hands  of  the  patient  to  the 
eyes  or  other  mucous  membranes  or  to  other  persons.  The  parts 
should  be  kept  dressed  with  gauze,  which  should  be  changed  fre- 
quently at  each  cleansing  and  irrigation  or  swabbing  with  antisep- 
tic solutions,  such  as  mercuric  bichloride  i  to  5000,  argyrol  5  to 
20  per  cent.,  protargal  2  to  10  per  cent.,  potassium  permanganate  i 
to  2000.  The  urine  should  be  rendered  bland  and  unirritating 
by  alkaline  diuretics  and  the  free  drinking  of  water. 

UNDESCENDED     TESTIS,    AND     MISPLACED     AND     HIDDEN 

TESTIS 

The  testes,  formed  in  the  abdomen,  usually  descend  into  the 
scrotum  during  the  ninth  month  of  fetal  life.  Yet  it  is  quite  com- 
mon to  find  in  the  male  infant  at  birth,  that  one  or  both  of  the 
testicles  are  absent  from  the  scrotum.  The  missing  organ  may 
sometimes  be  discovered  by  sweeping  the  finger  down  over  the 
inguinal  canal,  or  it  may  remain  hidden  quite  within  the  abdomen. 
In  many  of  these  cases  the  descent  is  completed  during  the  first 
few  weeks  of  life,  and  the  delay  is  scarcely  a  departure  from  the 
normal.  But  it  may  persist,  and  this  condition,  known  as  crypt- 
orchidism is  a  worrisome  malformation,  especially  if  both  testicles 
are  concealed  within  the  abdomen.  They  may  descend  at  some 
indefinite  time  before  puberty,  but  as  the  boy  grows  older  and 
they  fail  to  appear  the  chances  lessen,  the  anxiety  of  the  parents 
increases,  and  the  boy  himself  realizes  that  something  is  wrong. 
In  other  cases  the  testicle  descends,  but  through  some  misattach- 
ment  of  the  gubernaculum  testis  it  is  misguided  on  its  journeys, 
and  fails  to  enter  the  scrotum,  but  lodges  in  the  groin  or  peri- 
neum. 

This  latter  is  not  so  serious  a  matter,  as  the  wandering  organ 
may  functionate  out  of  its  usual  situation.  However,  it  incapaci- 
tates for  some  athletic  exercises  and  for  cavalry  service,  it  is  very 
apt  to  be  injured,  and  may  undergo  degeneration.  The  testicle 
that  remains  within  the  abdomen,  even  if  originally  of  normal  de- 
velopment, becomes  degenerated  and  valueless  by  the  time  it  should 
be  of  use.  It  may  become  inflamed  and  simulate  strangulated 
hernia,  or  become  gangrenous,  or  produce  peritonitis,  or  become 
the  seat  of  tumor  or  of  tubercular  disease.  A  testicle  that  lingers 
in  the  inguinal  canal  may  be  attached  to  a  loop  of  intestine  and  in- 
duce a  hernia  when  it  descends. 

The  diagnosis  presents  no  difficulty  if  one  only  remembers, 
in  case  of  finding  a  small,  elastic  and  usually  sensitive  swelling  in 
any  of  the  possible  situations  of  a  misplaced  testicle,  to  examine 
the  scrotum  as  to  whether  both  testes  are  in  their  right  places. 


THE  GENITO-URINARY   ORGANS  687 

Treatment. — In  the  very  young  subject  the  testicle  lingering 
in  the  inguinal  canal  may  be  assisted  in  its  descent  by  manipula- 
tion repeated  each  time  the  infant  is  diapered.  In  those  cases 
in  which  the  testicle  appears  sometimes  outside  of  the  abdomen 
and  again  disappears  within,  and  yet  is  not  attached  to  a  loop  of 
intestine,  it  may  be  caught  outside  and  prevented  from  returning 
within  by  the  application  of  a  truSs.  With  a  testicle  in  any  of  the 
erratic  situations  outside  of  the  abdomen,  operation  is  not  abso- 
lutely demanded  unless  the  misplaced  organ  is  painful ;  yet  it 
may  be  transplanted  to  the  scrotum.  As  an  exception  may  be 
noted  the  very  rare  instances  in  which  the  wandering  testis 
has  emerged  at  the  femoral  ring,  in  which  case  it  should  be  un- 
disturbed unless  too  troublesome,  when  it  should  be  removed.  If 
a  testicle  in  the  inguinal  canal  is  attached  to  a  loop  of  bowel  an 
operation  is  required,  both  for  bringing  down  the  testicle  and 
for  replacing  the  bowel  and  closing  the  inguinal  ring.  With  both 
testicles  retained  within  the  abdomen,  or  inguinal  canal,  or  unde- 
scended or  misplaced  upon  the  outside  of  the  body,  it  is  very 
desirable  that  one  or  both  should  be  transplanted  to  the  scrotum, 
or  at  least  liberated  from  the  abdominal  cavity. 

The  best  time  for  operation  is  after  the  boy  has  attained  sufifi- 
cient  age  and  strength  and  the  parts  are  large  enough  to  manipulate 
conveniently,  therefore,  not  until  the  sixth  year.  Yet  operation 
should  not  be  postponed  until  puberty,  as  the  organ  will  better 
undergo  the  developmental  changes  of  that  period  if  in  its  normal 
than  in  an  abnormal  situation.  Hence,  the  eleventh  or  twelfth 
year  is  a  favorable  age  for  the  operation.  Yet  if  an  associated 
hernia  demand  operation  at  an  earlier  age  it  may  be  done  in  con- 
nection with  the  hernia  operation  at  any  time  after  the  fourth 
year.  The  principles  of  the  operation  are  the  same  whatever  the 
situation  of  the  erratic  testis.  Bevan  has  considered  the  subject 
fully,^  and  his  directions  are  practicable.  First,  in  case  the  testi- 
cle is  in  the  inguinal  canal  or  outside  the  external  ring,  an  incision 
is  made  upon  the  canal,  from  the  external  ring  upward  and  out- 
ward a  distance  of  three  inches.  The  incision  does  not  involve 
the  scrotum.  The  aponeurosis  of  the  external  oblique  is  divided 
and  retracted  the  same  as  in  a  Bassini  operation  for  inguinal 
hernia ;  and  then  the  cremasteric  and  transversalis  fasciae  are  di- 
vided throughout  the  whole  length  of  the  wound.  The  testicle 
is  then  discovered  with  its  pouch  of  peritoneum.  The  peritoneum 
above  the  testicle  should  be  carefully  separated  from  the  cord, 
and  that  portion  of  it  in  contact  with  the  testicle  should  be  re- 
tained as  a  tunica  vaginalis,  being  cut  ofif  from  the  rest  and 
closed  with  a  purse  string  suture  of  catgut.     The  peritoneum  is 

*Jour.   Am.   Med.  Assn.,   Sept.    19,   1903. 


688  SURGICAL   DISEASES    OF   CHILDREN 

closed  with  ligature  or  suture.  The  testicle  is  now  lifted  from  its 
bed,  and  the  length  of  the  cord  is  tested,  and  increased  by  gently 
pulling  upon  it  and  freeing  it  by  blunt  dissection  from  short  bands 
of  connective  tissue  which  restrain  it.  All  surrounding  fascia 
should  be  stripped  from  the  cord,  leaving  nothing  but  the  vessels 
and  the  vas  which  should  b^e  freely  separated  from  the  peritoneum 
by  blunt  dissection.  By  these  means  the  cord  should  be  so  freed 
and  lengthened  that  the  testicle  may  be  brought  down  several 
inches  below  Poupart's  ligament.  If  the  cord  is  still  not  long 
enough  there  are  other  means  for  lengthening  which  will  be  de- 
scribed later.  The  fingers  are  now  passed  in  at  the  lower  angle 
of  the  wound  and  down  into  the  scrotum  and  form  a  pocket  there, 
in  which  the  testicle  is  placed.  The  mouth  of  the  pocket  is  closed 
by  suture  which  also  passes  through  the  internal  and  external  pillars 
of  the  ring,  above  the  cord,  but  is  not  drawn  tight  enough  to  exer- 
cise pressure  on  the  cord. 

The  wound  is  closed  as  in  the  Bassini  operation,  but  without 
forming  a  new  canal  for  the  cord;  that  is,  the  conjoined  tendon  and 
Poupart's  are  sutured  together  superficial  to  the  cord. 

Secondly,  in  case  the  testicle  is  within  the  abdominal  cavity, 
or  in  case  the  cord  is  not  sufficiently  lengthened  by  the  foregoing 
method,  the  inguinal  canal  should  be  opened  as  before  described. 
If  the  testicle  is  within  reach  it  should  be  drawn  out  at  the 
opening  with  the  finger  and  loosened  by  blunt  dissection.  It  will 
be  found  that  the  obstacle  to  the  descent  of  the  cord  is  not  the 
shortness  of  the  vas  but  of  the  spermatic  vessels  whose  integrity 
is  not  essential  to  the  nutrition  of  the  testicle.  The  testicle  re- 
ceives a  sufficient  blood  supply  from  the  artery  of  the  vas,  as  Ben- 
nett long  ago  taught.  The  spermatic  vessels  should  be  doubly 
ligated  and  divided ;  and  when  this  is  done  it  will  be  found  that 
the  testicle  can  be  brought  down  into  the  scrotum.  (53) 

Thirdly,  there  are  to  be  dealt  with  those  cases  in  which  the 
testicle  is  misplaced  in  the  perineum  or  upon  the  groin.  It  may 
be  that  only  a  few  fibers  of  the  gubernaculum  hold  it  in  the  abnor- 
mal situation,  and  when  these  are  divided  the  organ  is  readily 
placed  in  the  scrotum.  Or  if  this  fails  the  organ  is  exposed 
through  an  incision  and  with  the  cord  turned  up  toward  the  in- 
jured ring.  Then  by  tunneHng  under  skin  and  fascia,  or  by 
an  incision  abov,e  the  scrotum  and  the  formation  of  a  pocket  in 
that  receptacle,  it  is  transplanted  into  its  normal  site. 

SUPERNUMERARY  TESTIS 

One  occasionally  hears  of  a  supernumerary  testicle,  but  on 
coming  to  examine  the  boy  thus  favored  beyond  his  fellows,  one 
finds  a  hydrocel,e  or  a  hernia  or  a  tumor,  or  tuberculosis  of  the 
epididymis. 


THE    GENITO-URINARY    ORGANS  689 

TUMORS  OF  THE  TESTIS 

Tumors  of  the  testis  are  either  congenital  or  acquired,  and  are 
innocent  or  malignant.  Congenital  tumors  are  said  to  be  usually 
dermoids,  although  myoma,  adenoma,  enchondroma,  sarcoma  and 
carcinoma  have  b,een  reported.  Dermoids  of  the  testicles  are  ex- 
tremely rare  (see  Section  on  Dermoids  in  the  Chapter  on  Tumors), 
most  of  the  cases  reported  as  such  having  proved  to  be  dermoids 
of  the  scrotum.  Innocent  cysts  conn,ected  with  the  seminal  tubules 
occur.  But  all  innocent  tumors  of  the  testicle  are  very  rare  in 
children.  Carcinoma  less  frequently  occurs  than  sarcoma.  It  is 
usually  congenital  and  runs  an  extremely  rapid  course  to  a  fatal 
end.  Sarcoma,  th,e  most  frequent  of  the  malignant  tumors  of 
early  life,  is  a  disease  of  childhood  rather  than  of  infancy.  The 
tumor  usually  begins  in  the  epididymis  or  the  testis  itself  rather 
than  its  coverings.  It  is  generally  smooth  and  rounded  in  its  out- 
lines, and  heavy.  It  is  generally  hard,  although  it  is  apt  to  un- 
dergo cystic  degeneration  and  to  fluctuate  in  some  part.  In  these 
points  it  resembles  dermoid,  though  it  may  be  mistaken  in  the 
beginning  for  tubercular  epididymitis  or  gumma.  But  these  en- 
largements, and  all  innocent  neoplasms,  are  slow  in  growth,  while 
sarcoma  is  rapid. 

Treatment. — The  treatment  of  tumors  of  the  testicle  is  prompt 
removal.  The  innocent  tumors  would  do  no  harm,  at  least  for  a 
time.  But  with  the  malignant  growths  the  only  hope  lies  in  early 
and  complete  extirpation.  By  the  time  a  certain  diagnosis  of 
mahgnancy  can  be  made  it  may  be  too  late  to  prevent  a  recurrence 
after  removal.  If  the  lapse  of  time,  together  with  other  charac- 
teristics, has  already  proven  the  innocence  of  the  growth,  it  may 
not  be  necessary  to  sacrifice  the  testicle  in  the  removal  of  the 
tumor. 

ORCHITIS 

Acute  orchitis  usually  occurs  from  traumatism.  This  may  be 
either  accidental  injury,  or  surgical  trauma  in  the  neighborhood, 
such  as  operations  for  hernia  or  hydrocele,  or  the  pressure  of  a  truss 
upon  an  undescended  testicle  mistaken  for  a  hernia.  It  usually  sub- 
sides under  rest,  elevation  of  the  parts,  and  the  use  of  lead  and 
opium,  or  other  lotion.  Orchitis  from  mumps  and  gonorrhea  must 
be  extremely  rare  in  boys. 

TORSION   OF  THE   SPERMATIC   CORD 

This  curious  accident  I  have  never  met,  but  cases  have  been 
reported  by  Nicoladoni,  Bryant,  Owen,  and  others.  It  may  occur 
at  any  age,  though  most  frequently  in  adolescents  or  young  adults, 
and  is  more  apt  to  take  place  when  the  testis  has  not  completely  de-. 


690  SURGICAL   DISEASES    OF    CHILDREN 

scended  into  the  scrotum.  The  loose  suspension  of  the  testis,  while 
it  allows  of  escape  from  many  injuries,  seems  to  favor  this  acci- 
dent. Other  predisposing  causes  are  flat  shape  of  testis,  and  the 
flat  or  rather  double  shape  of  the  cord.  As  exciting  causes  various 
forms  of  violent  exercise  have  been  mentioned,  but  in  other  cases 
no  cause  is  given. 

The  spermatic  cord  is  found  to  be  twisted  upon  its  own  axis, 
having  turned  once  or  more,  and  is  strangulated  according  to  the 
degree  of  the  twisting  and  the  length  of  time  it  has  remained  in  that 
condition.  Inflammation  or  gangrene  may  have  supervened.  The 
tunica  vaginalis  contains  fluid.  Sloughing,  or  in  less  severe  cases 
atrophy  of  the  testicle,  may  result. 

Symptoms  and  diagnosis. — A  swelling  appears  in  the  scrotum, 
inguinal  canal,  or  groin,  together  with  pain  and  nausea,  a  quick 
pulse  and  symptoms  of  shock.  The  swelling  is  firm,  tender,  dull  on 
percussion  and  irreducible,  and  the  scrotum  may  be  reddened.  There 
is  no  impulse  on  coughing.  There  may  be  tension  of  the  abdominal 
muscles,  and  constipation.  Some  fever  is  usually  present  after  a 
time.  This  condition  in  a  boy  is  apt  to  be  mistaken  for  strangulated 
hernia,  or  for  traumatic  orchitis,  or  lymphadenitis.  But  if  torsion 
is  borne  in  mind  and  the  case  examined  attentively  such  a  mistake 
need  not  occur. 

Treatment. — An  incision  should  be  made  exposing  the  testicle 
and  the  cord  and  their  condition  examined.  If  the  inflammation 
has  approached  gangrene  the  testicle  would  better  be  removed,  for 
even  if  it  does  not  slough  it  will  atrophy.  But  if  the  tissues  appear 
viable  the  cord  should  be  untwisted  and  an  effort  made  to  relieve 
the  circulation  by  irrigating  with  a  hot  saline  solution,  or  to  subdue 
the  inflammation  if  that  is  present. 

VARICOCELE 

Occasionally  cases  of  varicocele  in  boys  have  been  reported. 
It  is  certainly  not  a  common  condition  in  childhood,  though  not 
infrequent  during  adolescence. 

TUBERCULOSIS  OF  THE  TESTICLE  AND  OF  THE  EPI- 
DIDYMIS 

Tubercular  orchitis  and  epididymitis,  either  singly  or  together, 
occur  not  infrequently  in  childhood  as  a  local  manifestation  or  as 
part  of  a  general  tuberculosis. 

Etiology. — The  disease  may  be  primary,  but  in  the  majority  of 
cases  general  infection  or  other  local  infection  precedes  that  of  the 
testicle  or  epididymis.  Direct  inheritance  of  tuberculosis  occurs 
with  extreme  rarity. 

Pathology. — The  tubercular   deposit  may   appear  first  in  the 


THE    GENITO-URINARY    ORGANS  691 

epididymis,  and  then  extend  to  the  cord  and  testis ;  or  it  may  occur 
in  the  testis  itself.  In  some  instances,  a  fibroid  chang-e  takes  place 
and  the  tubercular  masses  entirely  disappear.  In  other  cases  casea- 
tion occurs  as  with  tubercular  inflammation  elsewhere,  and  ab- 
scess forms  and  discharges.  This  is  especially  liable  to  occur  if 
pyogenic  organisms  gain  access  to  the  tubercular  focus.  In  mixed 
infections  the  lymphatics  are  more  likely  to  be  involved  and  other 
foci  to  become  infected  and  to  suppurate. 

Symptoms  and  Diagnosis. — The  disease  comes  insidiously,  often 
being  discovered  by  accident.  A  history  of  previous  traumatism 
may  be  given,  but  this  may  be  true  also  of  sarcoma,  of  hydrocele  and 
hernia  and  even  syphilitic  testitis.  A  swelling  is  found  in  the  tes- 
ticle or  the  epididymis  or  both.  The  swelling  is  painless  and  not 
tender,  nodular  or  irregular  in  outline,  hard,  and  grows  slowly. 
Occasionally  the  onset  is  more  acute.  If  it  suppurates  it  forms  the 
usual  sinuses  with  livid  edges,  and  runs  the  slow  but  persistent 
course  characteristic  of  tubercle.  In  suppurating  cases  there  are 
usually  other  local  manifestations  of  surgical  tuberculosis. 

Prognosis. — If  the  general  health  can  be  improved  and  the 
local  condition  be  properly  treated  the  trouble  may  subside,  although 
it  is  probable  that  the  testicle  will  subsequently  atrophy.  Extension 
to  the  vas  deferens,  vesiculse  and  bladder  is  not  common. 

Treatment. — General  treatment  for  tuberculosis  should  always 
be  thoroughly  and  perseveringly  carried  out.  (See  Section  on 
Tuberculosis.) 

Locally  a  suspensory  bandage  should  be  used.  Inunctions  of 
ointment  of  mercury  or  of  iodide  of  lead  are  useful.  Also  pressure 
by  bandage  or  strapping.  If  suppuration  persist,  or  if  the  part  be 
found  riddled  with  sinuses,  it  is  better  to  remove  it.  If  only  an  epi- 
didymis is  diseased,  it  may  suffice  to  remove  that  alone. 

SYPHILITIC  TESTITIS 

This  is  a  very  unusual  manifestation  of  lues  hereditaria.  Both 
testicles  are  apt  to  be  affected,  with  smooth  and  regular  swelling. 
The  epididymis  remains  free.  The  swelling  disappears  under  the 
use  of  mercury  internally,  or  locally  by  inunction,  and  of  potassium 
iodide. 

HYDROCELE  IN  THE  MALE 

Hydrocele  is  congenital  or  acquired.  The  congenital  form  is 
chronic,  the  acquired  may  be  acute  or  chronic.  The  congenital 
exists  because  of  a  fault  in  the  process  of  development  of  the  tunica 
vaginalis  testis,  its  watery  accumulation  being  derived  from  the 
peritoneal  cavity.  Other  variations  in  this  process  of  development 
determine  which  of  several  varieties  will  occur  if  the  disease,  acute 


692 


SURGICAL   DISEASES    OF   CHILDREN 


or  chronic,  is  acquired  as  a  result  of  some  irritation  of  the  serous 
sac.  Hydrocele  in  any  form  may  occur  upon  one  or  both  sides. 
(See  Fig.  235.) 

Development  of  the  tunica  vaghwlis  testis. — ^The  testicle  in  its 
developmental  descent  from  the  abdominal  cavity  to  the  scrotum, 
carries  with  it  upon  its  anterior  aspect  a  process  of  the  peritoneum. 
This  process  should  become  sealed  off  from  the  general  peritoneal 
cavity  at  the  internal  ring,  and  the  portion  of  it  which  extends  from 
the  ring  to  the  upper  end  of  the  testicle  should  become  obliterated 
as  a  cavity,  remaining  merely  as  a  strand  of  fibrous  tissue.   Only  the 


Fig.  235.     Double  congenital  hydrocele  and  umbilical  hernia. 


lower  end  of  the  serous  sac,  that  which  lies  in  front  of  the  testicle, 
should  remain  a  serous  cavity,  the  tunica  vaginalis  testis. 

Congenital  Hydrocele. — But  the  vaginal  process  may  fail  to 
separate  from  the  peritoneal  cavity,  and  being  filled  with  serous 
fluid  from  that  cavity  forms  a  congenital  hydrocele.  (Fig.  236.) 
This  appears  as  an  elastrc  swelling  in  the  scrotum  and  cord.  It  is 
translucent.  That  is,  if  in  a  darkened  room  a  light  be  held  at  one 
side  of  it  and  shaded  by  the  hand,  while  the  tumor  is  viewed  through 
a  spool  or  any  opening  a  third  of  an  inch  in  diameter  placed  against 
it  opposite  the  light,  it  appears  semi-transparent. 

A  solid  tumor  or  a  hernia  does  not  transmit  light  in  that  man- 
ner. The  fluid  from  this  hydrocele  can  be  gradually  squeezed  into 
the  abdomen  when  the  patient  is  recumbent,  and  on  releasing  the 
scrotum  and  the  ring,  with  patient  upright,  the  sac  gradually  refills." 
The  fluid  does  not  disappear  at  once  in  a  mass  as  a  hernia  might, 
nor  reappear  in  the  same  manner,  but  gradually,  as  the  fluid  runs 
through  the  narrow  opening  at  the  neck  of  the  sac.  Congenital  her- 
nia and  hydrocele  may  and  often  do  coexist.    Or  the  opening  of  the 


THE    GENITO-URINARY     ORGANS 


693 


hydrocele    may,    through    extra    strain,    be    enlarged    and    allow    a 
knuckle  of  intestine  to  protrude. 

Funicular  Hydrocele. — Separation  may  take  place  only  be- 


FiG.     236.       Congenital  Fig.      237.       Funicular  Fig.  238.    Infantile  hy- 

HYDROCELE.      Entire  hydrocele.      Funicular       drocele.    Vaginal  proc- 

vaginal     process      fills  process  only  fills  with       ess    a    short    sac    filled 

with    peritoneal     fluid.  peritoneal    fluid.                   with  fluid. 

tween  the  tunica  vaginalis  and  the  funicular  process,  leaving  the 
same  condition  as  that  of  congenital  hydrocele,  excepting  that  the 
testicle  with  its  serous  portion  is  below  the  swelling.     (Fig.  237.) 


Fig.  239.     Hydrocele  of   Fig.  240.     Hydrocele  of   Fig.  241.     Hydrocele  of 


THE  CORD.  Funicular 
process  only  distended 
with  fluid. 


THE    tunica    vaginalis 

TESTIS.  Funicular  proc- 
ess closed.  Tunica  vag- 
inalis  only   distended. 


THE     canal     of     NUCK. 

Corresponds  to  infan- 
tile hydrocele  in  the 
male. 


Infantile  Hydrocele. — Here  occlusion  of  the  opening  into  the 
peritoneal  cavity  has  taken  place,  and  fluid  accumulated  in  the  com- 
mon sac  of  the  tunica  vaginalis  and  funicular  process.  (Fig.  238.) 
The  swelling  presents  the  translucence  of  the  congenital  variety  and 
of  all  hydroceles,  but  it  does  not  yield  to  pressure  because  the  fluid 
does  not  escape.  The  tumor  is  somewhat  pear-shaped,  rounded 
below  and  pointed  at  the  inguinal  ring.  The  testicle  is  behind  and 
below  it. 

Hydrocele  of  the  Cord. — The  tubular  part  of  the  serous  pro- 


694  SURGICAL   DISEASES    OF   CHILDREN 

cess  corresponding  to  the  cord  has  become  separated  from  the  peri- 
toneum and  from  the  tunica  vaginalis,  and  is  distended  with  fluid. 
(Fig.  239.)  It  forms  a  firm  elHptical  swelHng,  between  the  testicle 
and  the  inguinal  canal,  sometimes  extending  quite  into  the  canal  to 
the  internal  ring.  This  variety  of  hydrocele  more  than  any  other 
is  apt  to  be  mistaken  for  a  solid  tumor  or  for  hernia.  Both  Holmes 
and  Owen  record  the  common  experience  of  seeing  children  wearing 
trusses  over  such  cysts.  Twice  in  the  last  two  months  cases  of  this 
kind  have  been  sent  to  me  as  "  irreducible  hernia,"  by  physicians. 
They  do  resemble  hernia,  and  the  test  for  translucence  cannot  be 
applied.  But  they  are  harder  than  a  hernia,  have  not  the  thickness 
at  the  neck,  are  very  regular  in  outline,  have  no  tympany  or 
gurgling. 

Hydrocele  of  the  Tunica  Vaginalis  Testis. — (Fig.  240.) 
Ordinary  hydrocele  is  less  frequently  met  in  children  than  the  other 
varieties.     Its  situation,  feel,  and  translucence  make  diagnosis  easy. 

Hydrocele  in  the  Female. — Hydrocele  may  occur  in  the  canal 
of  Nuck,  and,  being  sealed  off  from  the  peritoneum,  appears  as  a 
small,  firm,  painless,  subacute  or  chronic  swelling  between  the  ingui- 
nal canal  and  the  labium.      (Fig.  241.) 

Treatment. — Many  of  the  acute  hydroceles,  which  come  from 
no  very  clearly  defined  cause,  in  the  course  of  an  erythema  about 
the  genitals  or  buttocks  or  perhaps  from  squeezing  the  parts  between 
the  fat  thighs  of  the  infant,  disappear  spontaneously  after  a  few 
weeks ;  also  that  after  scarlet  fever.  If  there  is  any  possible  source 
of  irritation  in  the  neighborhood,  such  as  phimosis,  balanitis,  or  a 
skin  eruption,  this  should  be  treated.  The  swelling  should  be  so 
supported  that  it  is  not  caught  between  the  thighs.  The  congenital 
and  funicular  varieties  should  be  treated  by  trussing.  Very  likely 
the  opening  between  the  sac  and  the  abdomen  wall  close.  If  it  does 
not,  it  should  in  due  time  be  closed  by  operation  upon  the  same  prin- 
ciples as  the  radical  operation  for  hernia.  The  other  varieties,  if 
they  persist  after  several  weeks,  may  be  dissipated  by  one  or  two 
tappings.  If  this  does  not  cure,  some  advise  injecting  a  i  to  5000 
solution  of  mercuric  bichloride  or  a  wine-colored  solution  of  iodine, 
or  a  few  drops  of  carbolic  acid  in  glycerine,  into  the  sac.  The  irri- 
tant sets  up  a  moderate  inflammatory  reaction  in  the  lining  of  the 
sac,  which  stops,  the  extra  secretion. 

Injection  methods  should  never  be  tried  in  the  congenital,  funic- 
ular, or  infantile  varieties.  In  the  first  two  the  irritant  will  surely 
escape  into  the  peritoneal  cavity  and  cause  trouble.  In  the  infantile 
form  one  cannot  be  sure  the  separation  from  the  peritoneum  is  quite 
complete.  And  I  have  more  than  once  known  an  infantile  hydro- 
cele to  suddenly  disappear  into  the  abdominal  cavity,  presumably 
bursting  open  the  old  channel  which  had  been  closed.     Once  this 


THE    GENITO-URINARY     ORGANS 


695 


occurred  just  as  I  was  preparing  to  operate.  I  do  not  use  injections 
at  all ;  preferring,  if  anything  more  than  tapping  is  necessary,  one 
of  two  procedures.  One  is  to  lay  open  the  scrotum,  dissect  out  the 
sac,  tying  off  its  neck  and  closing  the  wound.  If  it  is  infantile  hy- 
drocele, a  small  portion  of  the  sac  may  be  left  below  to  serve  as  a 
tunica  vaginalis.  The  other  plan  is  to  lay  open  the  sac,  touch  its 
interior  walls  with  carbolic  acid,  removing  any  excess,  and  pack  the 
cavity  with  gauze  to  close  by  granulation,  or,  after  granulations 
form,  by  adhesion. 

CYST  OF  THE  SPERMATIC  CORD 

A  condition  may  occur  exactly  resembling  chronic  hydrocele 
of  the  cord  in  its  symptoms  and  external  appearance,  being  in  the 
same  situation,  oblong  in  shape, 
so  tense  as  to  seem  almost 
solid,  translucent,  not  very 
painful.  But  upon  operation 
it  is  found  that  by  careful  dis- 
section the  thin  walled  cyst 
can  be  removed  entire,  not  be= 
ing  continuous  at  either  end 
with  the  tunica  vaginalis  or 
the  fibrous  remains  of  the  funic- 
ular process.    (See  Fig.  242.) 

One  seldom  finds  any  ac= 
count  of  such  cysts  in  the  text- 
books. They  are  probably  not  hydroceles,  but  remains  of  the  hyda- 
tids of  Morgagni,  persisting  from  embryonic  life  and  developing  in 
cyst-like  form  in  close  proximity  to  the  spermatic  cord. 

Treatment. — They  may  be  treated  exactly  the  same  as  hydro- 
cele. Enucleation  is  a  much  nicer  method  than  by  opening  and 
cauterizing  with  carbolic  acid. 

MISPLACEMENT   OF  OVARIES 

Misplacement  of  ovaries  may  occur  either  congenitally  or  later. 
One  or  both  ovaries  may  be  found  in  the  inguinal  canal  or  the  canal 
of  Nuck,  or  in  the  femoral  canal.  They  may  be  reducible,  or,  be- 
coming attached  in  the  malposition,  may  be  irreducible  and  subject 
to  injury  like  the  misplaced  testis,  or  to  pain  and  swelling  at  the 
menstrual  periods.  Hernia  of  intestine  may  follow  the  wandering 
ovary. 

Treatment. — If  reducible,  a  truss  should  be  used.  If  irreducible 
and  giving  trouble,  an  operation  should  be  performed  restoring  the 
ovary  to  the  abdomen  and  closing  the  opening  as  in  the  radical  op- 
eration for  hernia. 


Fig.  242.    Cyst  of  the  spermatic 

CORD. 


696  SURGICAL   DISEASES    OF    CHILDREN 

OVARIAN  TUMORS 

Ovarian  tumors  may  occur  at  a  very  early  age,  being  some- 
times even  congenital.  They  are  either  innocent  or  malignant.  The 
innocent  tumors  are  simple  cystic,  fibroid,  or  dermoid  (or  tridermic 
— see  Chapter  on  Tumors).  The  malignant  tumors  are  either  sar- 
comata or  carcinomata,  the  former  being  far  more  common.  (54) 

Symptoms  and  Diagnosis. — It  is  sometimes  extremely  difficult 
to  make  a  diagnosis  before  operation  as  to  the  nature  of  the  tumor 
and  as  to  its  attachments.  Rapid  growth  and  ascites  point  to  ma- 
lignancy. A  tumor  that  is  freely  movable  is  more  apt  to  be  ovarian 
than  renal  or  hepatic.  If  ascites  is  present,  tapping  may  be  required 
before  the  tumor  can  be  palpated.  Examination  with  one  finger  in 
the  rectum  and  the  other  hand  over  the  abdomen  may  assist  in  locat- 
ing the  attachment.  Precocious  puberty  is  said  to  be  present  in  some 
cases  of  ovarian  tumors.  Ashby  and  Wright  mention  a  case  of  such 
premature  development  associated  with  a  tumor  of  liver  and  kid- 
ney. Hydronephrosis,  which  may  be  congenital,  hydroperine- 
phrosis,  cysts  of  the  mesentery,  hydatids  of  the  kidney,  tuberculous 
masses  in  the  mesenteric  glands,  tubercular  peritonitis,  pyosalpinx, 
and  in  older  children  retained  menses  and  precocious  pregnancy  are 
also  to  be  excluded. 

Treatment. — The  treatment  for  tumors  is  operation.  If  the 
tumor  is  innocent  and  has  not  too  many  or  too  close  attachments 
to  important  viscera,  it  can  be  successfully  removed  with  no  fear  of 
its  recurrence.  A  malignant  tumor  removed  early  and  completely 
may  not  recur.  But  in  most  cases  of  maligancy,  by  the  time  the 
growth  is  discovered,  the  diagnosis  made,  and  consent  to  operate  is 
secured,  the  neoplasm  has  made  such  headway  that  complete  re- 
moval is  impossible,  or  metastases  have  occurred.  Nothwithstand- 
ing  the  doubtful  prognosis,  prompt  operation  should  be  performed, 
as  without  it  the  case  is  entirely  hopeless. 

ADHESION    OF    THE    LABIA    MINORA 

This  is  a  fault  of  development,  although  it  may  be  that  adhesion 
occasionally  takes  place  from  inflammation.  The  labia  minora  may 
be  joined  from  the  posterior  commissure  to  the  urethra,  or  only  a 
part  of  the  way  forward.  The  complete  closure  is  well  shown  in 
Fig.  243.  By  drawing  the  labia  apart  with  the  fingers  they  are 
torn  asunder,  leaving  upon  each  side  a  slightly  oozing  linear  wound. 

These  should  be  kept  smeared  with  sterilized  oil  or  vaseline  or 
a  pledget  of  oiled  lint  be  kept  between  them  or  they  will  readhere, 
again  and  again.  To  separate  them  is  a  simple  matter  in  the 
infant  and  done  in  a  few  seconds  with  no  anesthetic.  But  if  left 
until  the  child  is  older  it  occasions  an  unpleasant  struggle  if  at- 


THE     GENITO-URINARY     ORGANS 


697 


tempted  without  anesthesia,  especially  if  it  must  be  repeated,  and 
if  not  remedied  before  puberty  the  adhesion  is  so  strong  as  to  re- 
quire cutting,  and  there  may  be  retained  menses  to  deal  with. 

ADHESION  OF  THE  CLITORIS  AND  ITS  PREPUCE 

Not  infrequently  young  girls  are  brought  because  of  adhesions 
between  the  clitoris  and  its  prepuce  which  are  supposed  to  be  giv- 
ing rise  to  a  train  of  symptoms  either  local  or  psychic  and  neurotic. 
There  are  physicians  and  writers  of  reputation  who  lay  considerable 


Fig.  243.    Adhesion  of  the  labia  minora. 

stress  upon  this  condition  as  a  frequent  cause  of  various  nervous 
phenomena  as  well  as  local  irritations.  Personally  I  have  very 
seldom  seen  marked  remote  effects  fairly  attributable  to  this  cause, 
and  do  not  believe  that  it  very  commonly  produces  serious  symptoms. 
Retained  smegma  may  cause  thigh-chafing  and  similar  practices. 
If  evident  adhesions  exist,  they  should  be  torn  through  with  a  blunt 
dissector  and  the  parts  thus  put  in  their  normal  condition. 


PROLAPSE  OF  THE  FEMALE  URETHRA 

The  mucous  and  submucous  layers  of  the  urethra  occasion- 
ally are  caused  to  protrude  by  repeated  and  excessive  straining. 
In  mild  cases  to  remove  the  cause  of  the  straining  and  use  an 
astringent  is  efficient  treatment.  It  may  be  necessary  to  remove 
the  redundant  membrane.  This  may  be  done  by  the  galvano  cautery 
without  hemorrhage  and  little  scarring,  or  by  radial  incisions. 


698  SURGICAL   DISEASES    OF   CHILDREN 

VULVITIS 

Vulvitis  may  be  herpetic,  gangrenous,  simple,  or  specific.  The 
herpetic  eruption  resembles  that  frequently  occuring  upon  the  lips 
and  face.  It  is  located  upon  the  mucous  membrane  or  skin,  or  both. 
Treatment  is  by  cleanliness,  and  astringent  or  soothing  lotions  or 
powders.  Gangrenous  vulvitis  has  been  discussed  under  Noma  in 
the  Section  on  Gangrene.  Both  simple  and  specific  inflammation 
of  the  vulva  so  frequently  attack  also  the  vagina,  that  it  will  be 
sufBcient  if  these  subjects  are  presented  in  connection  with  vulvo- 
vaginitis. 

VULVO-VAGINITIS,    SIMPLE    AND    SPECIFIC 

VuLVo-VAGiNiTis  is  either  simple  or  specific.  The  slight  catarrh, 
with  its  sticky  white  secretion,  often  found  at  the  vulva  of  the  new- 
born, is  so  common  and  so  mild  as  to  be  scarcely  more  than  normal, 
and  subsides  in  a  few  days  with  care  and  cleanliness.  Yet  with- 
out cleanliness  infection  may  take  place,  and  the  discharge  become 
profuse,  irritating,  and  persistent,  lasting  for  weeks.  (55) 

In  older  children  infection  of  the  vulva  and  vagina  with  various 
common  pyogenic  organisms  is  of  frequent  occurrence.  They  give 
rise  to  inflammation  with  profuse  purulent  discharge.  The  disease 
most  easily  attacks  those  who  have  suffered  from  the  acute  infec- 
tions or  other  lowering  diseases,  or  who  are  constitutionally  weak, 
or  strumous ;  and  it  is  favored  by  bad  hygiene,  uncleanliness, 
phthiriasis,  scabies,  acrid  urine,  seatworms,  rough  clothing,  and 
other  local  irritation. 

The  prognosis  is  good  if  the  condition  is  properly  treated. 
Lymphadenitis  with  suppuration  is  a  possible  complication. 

Treatment  of  the  simple  form. — All  contributing  causes  should 
be  removed.  Locally  cleanliness  and  mild  antiseptics  are  indicated. 
Free  irrigation  twice  or  more  a  day  with  solution  of  borax  or  alum 
or  cupric  sulphate,  or  saturated  solution  of  boracic  acid,  are  usually 
efficient.  Solution  of  mercuric  bichloride,  i  to  3000  or  i  to  4000, 
may  occasionally  precede  the  milder  solution.  All  washes  should 
be  comfortably  warmed.  After  irrigation  the  parts  should  be  dried 
and  dusted  with  impalpable  boric  powder.  The  inflamed  labia 
should  be  separated  by  a  pledget  of  gauze.  If  the  suppuration 
persists,  swabbing  once  or  twice  with  argyrol  solution,  10  per  cent., 
may  aid  the  irrigations  and  dusting.  Occasionally  an  intractable 
case  may  need  to  be  swabbed  through  a  speculum  with  2  per  cent, 
silver  nitrate,  or  need  touching  with  the  solution  at  one  or  two 
points. 

The  urine  should  generally  be  neutralized  by  the  use  of 
potassium  citrate  or  the  spirits  of  Minderer,  and  the  bowels  regu- 


THE     GENITO-URINARY     ORGANS  699 

lated.  Tonics  or  other  appropriate  constitutional  treatment  are 
usually  required.      Simple  vulvo-vaginitis  is  contagious. 

Specific  A\tlvo-vaginitis  is  due  to  the  gonococcus.  The 
source  of  the  infection  should  always  be  inquired  into,  and  any 
charge  of  rape  or  of  tampering  by  servants  or  others  accepted  only 
with  great  caution.  The  gonococcus  is  often  associated  wdth  the 
more  ordinary  pyogenic  staphylococci  and  streptococci.  It  is  met 
sometimes  in  private  practice  but  more  often  in  institutions  where 
it  sometimes  takes  the  form  of  an  epidemic  and  is  exceedingly 
difficult  to  control.  The  discharge  may  at  first  appear  slight  and 
quite  innocent,  or  a  patient  may  be  admitted  to  hospital  suffering 
with  an  injury  or  an  acute  general  disease  like  measles  or  scarlet 
fever,  which  quite  distracts  attention  from  the  local  inflammation 
until  the  infection  has  already  been  disseminated.  Or  a  case  after 
treatment  may  appear  to  be  cured  and  then  have  a  recurrence  and 
communicate  the  infection  to  others;  or  it  may  be  conveyed  by 
clothing,  toys,  utensils,  etc. 

Symptoms  and  Course. — After  an  incubation  period  of  two 
to  ten  days  the  discharge  begins.  This  may  be  preceded  by  malaise, 
and  fever,  and  even  by  chills.  The  pus  is  yellow,  often  greenish, 
usually  thick  and  viscid,  and  remarkably  copious.  The  mucous 
membrane  becomes  hot  and  swollen  and  tender.  Micturition  may 
be  painful,  either  from  the  urine  coming  in  contact  with  the  vulvar 
mucosa  or  from  invasion  of  the  urethra  by  the  inflammation,  which 
latter,  however,  occur  less  frequently  in  children  than  in  adults. 
Pruritis  may  be  present.  The  acute  stage  of  the  disease  runs  its 
course  in  from  one  and  a  half  to  three  wrecks,  when  it  subsides,  but 
continues  in  a  subacute  or  slumbering  form,  often  to  be  roused 
to  activity  again,  when  treatment  is  discontinued  or  from  some 
cause  not  always  traceable.  The  contagion  may  at  any  time  be  con- 
veyed to  others,  or  to  other  parts  of  the  same  patient,  especially  the 
conjunctivse.  Or  the  endocardium,  the  joints,  or  the  peritoneum, 
may  become  secondarily  inflamed,  causing  very  serious  or  fatal 
results.  In  some  cases  the  damage  to  the  genito-urinary  organs 
is  less  than  one  would  expect  from  the  virulence  of  the  inflam- 
mation, but  in  others  it  is  as  bad  as  could  be,  extending  finally  to 
the  bladder,  kidneys,  uterus,  and  Fallopian  tubes,  and  if  the  child 
survives  to  womanhood,  producing  sterility,  besides  distressing- 
chronic  pelvic  disorders. 

Diagnosis. — The  diagnosis  may  be  made  clinically  by  the  symp- 
toms as  described ;  but  can  only  be  absolutely  differentiated  by  the 
finding  of  the  Neisser  organism  with  the  miscroscope. 

Treatment. — A  most  important  part  of  the  treatment  is  pre- 
vention. To  this  end,  every  case  of  vulvo-vaginal  discharge  should 
be  subjected  to  the  microscopic  test,  and  in  an  institution  especially, 


700  SURGICAL  DISEASES  OF  CHILDREN 

it  should  be  isolated  until  its  innocence  is  proven.  Children's  hospi- 
tals should  make  it  a  rule  to  examine  smear  preparations  from  the 
vaginal  discharge  of  every  female  child  before  admission. 

Specific  vulvo-vaginitis  must  be  isolated,  and  antisepsis  carried 
out  with  every  detail  of  the  nursing.  The  vulva  must  be  kept  cov- 
ered by  a  sterilized  absorbent  pad  of  gauze  or  cotton,  which  should 
afterward  be  burned.  Each  case  must  have  its  own  thermometer, 
utensils,  clothing,  and  bed  clothing.  All  fabrics  should  afterward 
be  boiled  in  bichloride,  i  to  looo,  and  utensils  boiled.  Vigilance 
should  not  be  relaxed  upon  the  subsidence  of  the  symptoms.  If, 
after  thorough  treatment  has  been  entirely  discontinued  for  a  period 
of  four  weeks,  a  series  of  smears  show  no  gonococci,  it  is  probable 
that  the  trouble  is  at  an  end,  and  will  not  be  communicable. 

Treatment  is  by  germicides  and  by  vaccines.  Free  irrigation 
by  means  of  a  soft  catheter  passed  to  the  uterus,  with  solution  of 
mercuric  bichloride,  i  to  3000  or  i  to  4000,  or  with  saturated  solu- 
tion of  boric  acid,  or  a  solution  of  potassium  permanganate,  i  to 
2000,  or  Condy's  fluid,  should  keep  the  parts  free  from  pus  even  if 
it  must  be  practiced  every  hour  or  two.  But  these  are  not  sufficient. 
A  speculum  ^  should  be  introduced  and  the  entire  vagina  carefully 
swabbed  from  above  downward  with  a  two  per  cent,  solution  of 
silver  nitrate,  or  fifteen  per  cent,  of  argyrol.  A  wick  of  gauze 
which  has  been  rubbed  in  powdered  boric  acid  should  then  be  de- 
posited in  the  entire  length  of  the  vagina  and  left  as  the  speculum 
is  withdrawn.  This  speculum  treatment  may  be  repeated  two  or 
three  times  a  day  at  first  till  the  discharge  lessens,  then  once  a  day, 
the  irrigation  being  continued.  In  some  cases  the  disease  will  be 
harbored  in  a  sulcus  of  the  vagina,  or  a  tuft  of  granulations,  and 
persist  in  recurring  until  that  is  treated  with  solutions  of  argyrol 
or  protargol,  or  with  silver  nitrate  two  per  cent,  or  touched  with  ten 
or  twenty  per  cent,  silver  nitrate. 

So  called  vaccines,  suspensions  in  a  normal  salt  solution  of  a 
definite  number  of  killed  gonococci,  have  proved  useful,  especially 
in  children  rather  than  in  infants,  and  more  uniformly  in  subacute 
and  chronic  than  in  acute  cases.  The  use  of  stock  vaccines  is  prac- 
ticable. In  my  own  cases,  the  majority  of  them  obstinate  and  of 
long  standing,  improvement  and  apparent  cures  have  been  effected. 
In  some,  the  disease  has  recurred  after  long  intervals,  when  not 
followed  up  with  local  treatment.  Many  observers  have  reported 
brilliant  results.^  One  may  dispense  with  the  opsonic  index  and 
be  guided  by  clinical  symptoms.      (60.) 

1  Dr.  Kelly's  cystoscope  No.  8,  9,  or  10. 

-Butler  and  Long:  Jour.  Am.  Med.  Assn.,  Mar.  7,  1908.     Wallace  Hamil- 
ton :  Jour.  Am.  Med.  Assn.,  Apr.  9,  1910.     Alice  Hamilton  and  J.  M.  Cook. 


CHAPTER  XXV 

HARE-LIP,    CLEFT^PALATE,    AND    THE    MOUTH, 
TONGUE,  FACE  AND  NECK 

Hare-Lip  and  Cleft-Palate — Macrostoma — Microstoma  and 
Atresia  Oris — Congenital  Absence  or  Malformation  of 
THE  Tongue — Macroglossia — Papilloma,  Nevus  and  Fi- 
broma of  the  Tongue — Cysts  beneath  the  Tongue — 
Tongue  Tie — Epulis — Supernumerary  Auricles  and 
Branchial  Fistulae — Coloboma  of  the  Eyelid — Epican- 
thus. 

HARE-LIP   AND    CLEFT-PALATE 

The  term  hare-lip  (labium  leporinum)  is  applied  to  a  condi- 
tion of  malformation  due  to  arrested  development,  presenting  a 
fissure  or  fissures  extending  mor.e  or  less  deeply  into  the  tissues 
from  the  margin  of  the  lip.  The  name  is  not  properly  applied  to 
the  results  of  disease  or  traumatism.  The  deformity  is  a  rather 
common  one,  is  very  disfiguring  to  the  patient,  and  distressing 
to  his  friends,  and  the  surgeon  is  frequently  besought  to  remedy 
the  defect.  Cleft-palate  (fauces  lupinum,  or  wolf-throat)  is  a 
common  and  serious  malformation,  in  which  the  hard  or  soft 
palate,  or  both,  retain  the  embryonic  form,  and  are  more  or  less 
incapable  of  performing  their  functions  in  speech  and  deglutition, 
and  in  separating  oral  and  nasal  cavities. 

Etiology  and  Varieties. — At  the  25th  to  the  28th  day  of  fetal 
life  the  face  is  undergoing  deyelopment.  Just  previous  to  this 
the  face  is  all  mouth,  back  as  far  as  the  situation  of  the  ears,  and 
overhung  by  the  frontal  prominence.  Four  projections  now  ap- 
pear at  each  side  of  the  neck  and  grow  toward  the  median  line, 
in  the  same  manner  as  the  visceral  plates  close  in  to  form  the 
abdomen  and  thorax.  These  projections  are  called  the  branchial 
arches,  and  the  superior  one  of  these  arches,  in  connection  with 
the  fronto-nasal  process  which  extends  downward  from  the  fore- 
head, is  destined  to  form  the  face. 

This  superior  arch  soon  presents  two  secondary  projections — 
the  lower,  called  the  mandibular  process  of  the  arch,  uniting  in  the 
median  line  with  its  fellow  of  the  opposite  side,  forms  the  inferior 
maxilla;  the  upper  second  projection  of  the  superior  arch,  called 

701 


702 


SURGICAL   DISEASES    OF    CHILDREN 


the  maxillary  process,  grows  forward  to  meet  the  fronto-nasal  or 
intermaxillary  process  descending  to  form  the  vertical  plate  of  the 

ethmoid  and  the  vomer  and  the  in- 
termaxillary in  front,  with  which  it 
unites  to  form  the  upper  jaw,  leav- 
ing openings  for  the  nostrils.  The 
fronto-nasal  process  is  at  first  di- 
vided at  its  lower  end,  but  this 
notch  in  the  middle  disappears  and 
the  incisive  process,  which  later  de- 
velops the  two  middle  incisor  teeth, 
is  formed  at  the  extremity  of  the 
fronto-nasal  or  intermaxillary  pro- 
cess. The  maxillary  processes  also 
form  the  outer  wall  of  the  orbit  and 
the  malar  bone,  and,  together  with 
the  lateral  plates  of  the  fronto-nasal 
process,  from  the  floor  of  the  orbit. 
They  also  extend  toward  the  median 
line,  and  by  joining  the  mid-frontal 
process  they  complete  the  formation 
of  the  superior  maxilla,  including 
the  alveolar  arches.  The  alveolar 
arches,  shelving  inward  from  each 
side,  form  palatal  processes  which 
should  meet  in  the  middle  line,  and, 
together  with  the  deep  aspect  of  the 
fronto-nasal  process,  complete  the 
palatal  arch.    (See  Fig.  244.) 

It  will  be  observed  that  the  lateral 
halves  of  the  mandibular  arch  unite 
early  and  strongly,  and,  as  might  be 
inferred,  a  fissure  of  the  lower  lip 
is  seldom  met  with,  although  a  few 
cases  have  been  reported.  The  usual 
seat  of  the  malformation  is  the 
upper  jaw.  Here  a  considerable 
variety  in  form  and  extent  of  mal- 
formation may  be  found.  A  failure 
of  the  maxillary  process  to  unite  with 
the  fronto-nasal  process  upon  one 
side  results  in  a  single  or  unilateral  hare-lip.  If  the  failure 
occurs  upon  both  sides  we  have  a  double,  or  bilateral,  hare-lip. 
The  development  may  be  almost  complete,  leaving  a  mere  notch 
with    a    groove,    furrow,    or    seam   above    it;    or   it   may   extend 


Fig.    244.      Mouth    of    an 

EMBRYON   OF  FORTY   DAYS.     After 

Coste,  as  described  in  Flint's 
Physiology.  I,  first  appear- 
ance of  the  nose;  2,  2,  first  ap- 
pearance of  the  alae  of  the 
nose;  3,  appearance  of  the 
closure  beneath  the  nose;  4, 
median  portion  of  the  upper 
lip,  formed  by  the  approach 
and  union  of  the  two  incisor 
processes,  a  little  notch  in  the 
median  line  still  indicating  the 
primitive  separation  of  the  two 
processes ;  5,  5,  superior  maxil- 
lary processes,  forming  the 
lateral  portions  of  the  upper 
lip ;  6,  6,  groove  for  the  de- 
velopment of  the  lachrymal 
sac,  and  the  nasal  canal';  7, 
lower  lip ;  8,  mouth ;  9,  9,  the 
two  lateral  halves  of  the  pala- 
tine arch,  already  nearly  ap- 
proximated to  each  other  in 
front  but  still  widely  separated 
behind ;  10,  remains  of  the 
branchial  arches,  still  showing 
fissures  between  them. 


MOUTH,    TONGUE,    FACE    AND    NECK 


703 


clear  through  the  lip  up  into  the  nostril,  or  even  into  the  alveo- 
lar process  of  the  upper  jaw,  or  rarely,  as  in  that  curious  case 
figured  by  Guersant,  the  fissure  may  extend  to  the  lower  eye- 
lids. A  cleft  in  the  alveolar  arch  passes  between  the  central  and 
lateral    incisors,    or    perhaps    eliminates    the    lateral    incisor.     In 


Fig.  245.  Single  hare-lip  with 
A  WIDE  CLEFT,  ill  which  the  in- 
termaxillary bone  is  visible. 
Note  also  flattening  and  wid- 
ening of  light  nostril,  due  to 
absence  of  bone  beneath  it  and 
to  unopposed  muscular  traction. 


Fig.  246.  Same  case  as  245,  after 
operation.  To  illustrate  faulty 
result  due  to  inaccurate  approx- 
imation, or  to  yielding  of  sut- 
ures under  muscular  tension. 
Also  contour  of  nostril  and  mus- 
cular balance  are  not  restored. 


double  hare-lip  the  fissures  may  be  alike  on  the  two  sides,  or  one 
may  be  extensive  and  the  other  slight ;  or  one  a  mere  notch  and  the 
other  a  groove;  or  either  one  side  or  both  sides  connected  with  a 
cleft  in  the  palate.  In  either  the  single  or  double  variety  the  inter- 
maxillary bone  may  or  may  not  project,  or,  in  the  double  hare-lip, 
it  may  be  either  covered  or  not,  with  a  central  portion  of  lip.  A 
fissure  may  be  wide  or  narrow.  In  some  cases  the  margins  of  the 
fissures  are  quite  vertical,  as  though  there  was  little  lack  of  tis- 
sue, or  one  or  both  margins  may  slope  away  from  the  fissure. 
(Compare  Figs.  247  and  248.)  But  in  all  cases  the  fissure  is  more 
or  less  perpendicular  and  the  red  margin  of  the  lip  extends  upon 
the  margins  of  the  fissure. 

Median  Hare-lip,  the  only  variety  which  exactly  resembles 
the  normal  lip  of  the  hare,  and  from  which  the  name  of  the  deformity 
is  doubtless  taken,  is  exceedingly  rare,  although  well  authenticated 
cases  are  on  record.     I  presume  this  would  arise  in  a  permanence 


704 


SURGICAL    DISEASES    OF    CHILDREN 


of  the  notch  at  the  lower  end  of  the  fronto-nasal  process,  or  an 
absence  of  the  incisive  process.  Entire  absence  of  the  upper  lip 
has  occrurred. 

In  case  the  palatal  processes,  springing  from  the  alveolar  arches 
at  either  side,  fail  to  coalesce  in  the  median  line,  the  palatal  arch 
is  incomplete  and  the  mouth  is  not  separated  from  the  nasal-fossse. 

In  other  words,  we  have  a 
cleft  palate.  This  mal- 
formation may  vary  great- 
ly in  degree,  the  cleft  in- 
volving only  the  uvula,  or 
only  the  soft  palate,  or 
both  soft  and  hard  palates. 
The  hard  palate  may  be 
cleft  only  as  far  forward 
as  the  alveolar  arch,  or 
it  may  connect  with  a 
hare-lip  completely  divid- 
ing the  arch  (Fig.  250), 
and  this  may  occur  upon 
one,  or,  more  rarely,  upon 
both  sides.  The  cleft  in 
the  soft  and  in  the  poste- 
rior part  of  the  hard  palate 
is  in  the  median  line,  but 
forward  it  deviates  laterally 
to  the  line  of  junction  of 
the  maxilla  with  the  inter- 
maxillary bone. 

Considering  the  mode  of  origin  of  hare-lip  and  cleft  palate, 
one  might  expect  to  find  them  associated  with  other  failures  of 
coalescence  of  the  lateral  halves  in  or  near  the  median  line,  such 
as  hypospadias,  epispadias,  spina  bifida,  meningocele,  hernia  cerebri, 
or  ventral  hernia,  and  yet  it  is  said  that  such  do  not  more  fre- 
quently occur  in  connection  with  hare-lip  than  other  deformities. 
It  is  agreed  by  all  writers  that  heredity  is  a  prominent  factor  in 
the  production  of  hare-lip.  As  an  example  of  a  not  unusual  family 
history  I  will  cite  the  case  of  A.  P.  (Seen  in  Figs.  245  and 
246.) 

There  was  no  deformity  known  on  the  mother's  side,  but  her 
paternal  great-grandfather,  an  aunt  (sister  of  her  father),  and 
a  cousin  (child  of  her  father's  brother)  all  had  hare-lip.  Yet 
numerous  children  escaped  the  deformity ;  for  example,  the  parents 
of  A.  P.  had  two  older  children  well  formed.  Sometimes  in  such 
a  family  other  members  may  exhibit,  on  close  inspection,  some  slight 


Fig.  247.  Hare-lip,  shown  for  compari- 
son with  248,  the  margins  of  the  cleft 
being  more  abundant  and  of  normal 
thickness  and  of  greater  length  from 
above  downward.  The  ala  of  the 
nostril  must  be  brought  up  toward  the 
middle  line.  This  is  a  much  simpler 
case  for  operation  than  248  and  was 
fully  restored  by  a  Mirault  operation. 


MOUTH,   TONGUE,    FACE   AND    NECK 


705 


defect  in  the  region  of  the  family  mark.  Occasionally  the  failure 
of  development  in  the  middle  line  may  take  a  different  form  in 
different  generations  or  in  different  children ;  for  instance,  the  father 
of  the  boy  with  extroversion  of  the  bladder,  shown  in  Fig.  228, 
had  a  hare-lip.  In  another  instance  under  my  observation  the 
first  child  in  a  family  had  hare-lip  and  imperforate  anus,  the  sec- 
ond was  normal,  and  the  third  had,  in  the  occipital  region,  a  menin- 
gocele larger  than  its  cranium.     As  to  other  possible  causes,  that 


Fig.  248.  Hare-lip  in  which  although 
actual  opening  is  not  wide,  the  lip 
is  short  and  tapers  up  to  the  cleft. 
The  lip  is  also  thin,  and  the  thin- 
ness extends  into  the  nostril  which 
is   deformed.     See  Fig.  249. 


Fig.  249.  Same  case  as  248  after 
operation.  The  thinness  of  the  lip 
has  been  removed  clear  into  the 
nostril,  lip  united,  lengthened  from 
above  downward,  and  the  shape  of 
the   nose   corrected. 


of  maternal  impressions  is  still  recurring  as  a  moot  question.  Doubt- 
less in  most,  if  not  every,  instance  any  connection  between  "  impres- 
sion "  and  malformation  is  imaginary.  Certainly  every  supposed 
case  of  the  kind  should  be  rigidly  criticised,  and  with  the  fullest 
knowledge  of  embryology.  A  child  afflicted  with  hare-lip  or  cleft 
palate  may  be  perfectly  normal  in  every  other  way,  and  of 
average  strength  and  vitality,  but  as  a  rule  he  is  below  the  average 
in  constitutional  vigor. 

Treatment. — There  is  no  cure  without  operation.  The  first 
question  to  decide  is  when  the  operation  shall  be  made;  and  the 
next,  how  shall  the  case  be  managed  in  the  meantime.  Many  sur- 
geons, notably  the  French  of  one  or  two  generations  ago,  have 
preferred    to   operate   immediately   after   birth,   and    the   literature 


7o6  SURGICAL    DISEASES    OF    CHILDREN 

lack  of  space  prevents  my  presenting.     I  can  only  state  my  own 
views,  which  are  shared  by  many  other  surgeons. 

Muscular  action  uncorrected  increases  the  deformity.  As  age 
advances  the  intermaxillary  bone  becomes  more  rigidly  ossified, 
and  w^hen  projecting  is  hard  to  replace,  and  the  teeth,  developed  in 
bad  positions,  either  increase  the  difficulties  of  the  closure  or  must 
be  removed.  ^Moreover,  the  sensibilities  of  the  parents,  and  of  the  ■ 
child,  which,  subject  to  observation  and  remark,  becomes  conscious 
of  its  condition,  have  a  right  to  be  considered.  I  consider  it  desir- 
able to  close  the  lip  as  early  as  possible,  compatible  with  safety  and 
a  good  result.  The  early  growth  and  development  of  the  child 
after  operation  will  give  the  plastic  work  a  more  natural  appear- 
ance, and  if  cleft  palate  also  be  present  the  closure  of  the  lip  gives 
a  decided  impulse  toward  a  natural  lessening  of  the  cleft  in  the 
palate  (compare  Fig.  250  with  Fig.  251),  and  gives  a  better  blood 
supply  to  the  parts  when  that  operation  is  performed.  It  has  been 
urged  as  an  objection  against  closing  the  lip  before  the  palate  that 
the  palate  is  more  easily  accessible  to  the  operator  with  the  lip 
open.  The  difference  in  convenience  is  not  great,  and  the  difficulty 
of  the  palate  operation  is  not  lack  of  room  between  the  lips,  as 
enough  can  be  secured  after  the  lip  is  closed.  I  think  it  must  be 
under  very  exceptional,  circumstances  that  the  palate,  cleft  to  any 
marked  degree,  should  be  closed  in  the  first  few  weeks  or  months 
of  an  infant's  life.  The  operation  is  too  severe  to  justify  the  risk. 
It  may  sometimes  be  advisable  to  close  a  part  of  a  cleft  early ;  as, 
for  example,  the  alveolar  process  or  the  hard  palate.  But  a  regular 
urano-staphyloraphy  should  be  postponed  at  least  until  the  second 
year,  and  perhaps  longer.  As  for  the  operation  of  forcing  together 
the  superior  maxillary  bones  to  bring  the  palatal  process  together,  a 
plan  well  known  as  the  Brophy  operation,  its  use  has  been  discon- 
tinued by  many  practical  surgeons  who  have  seen  much  of  its 
results.  By  means  of  a  needle  made  for  the  purpose,  Brophy  passes 
two  or  more  strong  silver  wires  laterally  through  the  superior 
maxillary  bones  from  side  to  side,  inside  of  the  cheeks.  These  wires 
are  threaded  through  holes  in  lead  plates,  which  are  placed  along 
outside  of  the  alveolar  processes ;  and  by  pressing  with  the  hands  and 
twisting  together  the  wires  the  two  sides  of  the  face  are  approxi- 
mated, and  the  edges  of  the  palatal  cleft,  having  been  previously 
freshened,  are  brought  together  and  sutured.  If  the  bones  are  too 
rigid  to  yield  to  this  force  they  are  incised  by  passing  a  knife 
through  a  small  opening  in  the  mucous  membrane  above  the  alveolar 
process  and  cutting  toward  the  median  line.  Brophy  prefers  to 
operate  when  the  infant  is  three  months  of  age,  and  his  operation 
is  not  applicable  after  the  sixth  month.  The  objections  to  this 
procedure    are   not   only   high   mortality    from    shock,    sepsis,    and 


MOUTH,    TONGUE,    FACE    AND    NECK 


707 


Ocd 

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7o8  SURGICAL    DISEASES    OF    CHILDREN 

meningitis,  but  results  that  appear  afterward,  such  as  contraction 
of  the  palate,  narrowing  of  the  posterior  nares,  irregular  occlusion 
of  the  teeth  and  damage  to  the  teeth  while  yet  in  their  formative 
state  by  passing  the  wires  through  the  superior  maxilla.  As  to 
speech,  as  Ferguson  says,  while  in  Brophy's  operation  the  palatine 
attachments  of  the  tensor  palati  and  the  levator  palati  are  not 
interfered  with  in  the  least,  still  it  has  yet  to  be  shown  that  the  into- 
nation is  better  than  that  obtained  by  other  plastic  operations. 

A  new-born  babe,  fairly  strong,  but  with  a  hare-lip  which  pre- 
vents it  from  nursing,  may  be  better  able  to  undergo  operation  im- 
mediately than  if  one  waits  until  it  is  older  without  giving  it  any  more 
than  ordinary  attention.  But  there  are  means  of  taking  especial  care 
of  it,  and  usually  nutrition  can  be  maintained,  and  I  prefer  to  wait 
at  least  until  the  time  for  the  dangers  of  septic  infection,  icterus 
and  the  other  diseases  especially  incident  to  the  new-born,  has 
passed  by.  In  the  meantime  the  babe  should  be  prepared  for  the 
operation. 

Treatment  Preliminary  to  Operation. — Immediately  after  the 
birth  of  a  babe  with  hare-lip,  whether  or  not  it  has  also  cleft  palate, 
means  should  be  used  to  prevent  increase  of  the  deformity  by  trac- 
tion of  unopposed  muscles.  Muscular  traction  tends  to  widen  the 
cleft,  not  only  of  the  soft  parts,  but  also  of  the  bones  when  the 
palatal  and  lip  cleft  are  one;  and  it  greatly  distorts  the  nose,  flatten- 
ing the  ala  on  the  side  of  a  single  cleft  and  drawing  the  septum, 
toward  the  opposite  side,  beyond  the  middle  line.     (See  Fig.  250.) 

Muscular  action  can  be  controlled  by  a  Hainsby's  truss  or  sim- 
ilar device ;  but  the  easiest  and  best  method  is  simply  to  draw  the 
margins  as  near  together  as  may  be  comfortable,  and  apply  a  strip 
of  adhesive  plaster,  of  the  width  of  the  lips,  transversely  across 
the  face.  This  strap  should  be  renewed  at  intervals  of  a  day  or 
a  few  days  or  longer,  as  necessary,  with  due  care  to  preserve  the 
skin  from  irritation.  Cleansing  the  skin  with  boric  acid  solution  and 
using  zinc  oxide  plaster  will  favor  a  sound  skin.  The  strapping  does 
more  than  control  and  equalize  muscular  action.  It  enables  the 
babe  to  nurse  better ;  accustoms  it  to  breathing  through  the  nostrils, 
so  that  its  breathing  is  less  embarrassed  when  the  lip  is  subse- 
quently closed  by  operation;  it  aids  in  preventing  irritation  of 
the  mucous  lining  of  the  nasopharynx  by  the  free  inrush  of  cold 
and  dust-laden  air;  it  accustoms  the  babe  to  restraint  of  the  parts, 
so  that  he  does  not  fret  under  tension  of  sutures.  Besides  all 
these  advantages,  simply  strapping  renders  the  deformity  far  less 
unsightly  and  distressing  to  the  parents  and  friends. 

It  may  be  necessary  to  pump  the  milk  from  the  breast  of  the 
mother  or  wet  nurse  and  feed  the  baby  with  a  spoon,  or  to  nourish 
it  with  modified  milk  or  other  food,  or  to  use  a  rubber  nipple  with 


MOUTH,    TONGUE,    FACE    AND    NECK  709 

an  obturator  attachment,  to  close  the  palate  cleft,  or  if  it  cannot 
suck,  gavage  may  work  a  wonderful  change  in  its  condition  and 
bring  it  up  to  a  state  fit  for  operation.  It  is  often  a  very  nice 
point  to  judge  whether  an  infant  is  in  fit  condition  for  operation, 
or  if  not  in  as  good  condition  as  one  could  wish,  whether  it  is  ever 
likely  to  be  better.  An  operation  upon  a  marasmic,  ill-conditioned 
infant,  or  one  afflicted  with  purulent  rhinitis  or  stomatitis,  is  fore- 
doomed to  failure,  or  even  a  fatal  result.  Snuffles  or  purulent  rhinitis 
should  be  overcome  before  an  operation  is  attempted,  for  in  the  oper- 
ation for  hare-lip  primary  union  is  essential.  To  put  such  an  infant 
into  a  thrifty  state  of  nutrition,  with  sound  tissues,  and  then  operate 
for  extensive  hare-lip  and  bring  it  through  successfully,  and  then 
close  the  palate  and  get  a  good  result,  is  no  mean  test  of  a  pediatric 
surgeon's  skill. 

If  all  is  going  satisfactorily  it  may  be  well  to  wait  until  the 
babe  is  from  a  few  weeks  to  a  few  months  old,  and  vigorous  enough 
to  bear  the  operation  and  in  condition  to  secure  repair,  but  before 
ossification  or  dentition  have  advanced  if  the  alveolar  process  is 
implicated  in  the  cleft.  The  lip  is  then  closed.  A  year  or  more 
later — perhaps  when  the  infant  is  a  year  and  a  half  or  two  years 
old,  and  vigorous  enough  for  the  major  operation — the  palate  may 
be  closed.  Even  then,  if  there  is  doubt  of  its  health,  the  operation 
may  be  deferred  without  fear  of  failure  in  restoring  satisfactory 
speech.  Or  it  is  sometimes  better  to  close  the  palate  in  two  stages — 
the  hard  palate  first  (uranorrhaphy),  and  then,  after  the  patient  has 
recuperated,  the  closure  of  the  soft  palate  (staphylorrhaphy)  com- 
pletes the  work.  In  a  patient  coming  late,  with  a  cleft  involving 
only  the  soft  palate  and  the  lip,  one  may  choose  to  operate  upon 
the  palate  first  and  to  strap  the  lip  for  a  while  during  the  recuperative 
period,  and  then  to  close  the  lip. 

Operative  Treatment. — The  history  of  the  operations  for  hare- 
lip (cheiloplasty),  and  for  cleft  palate  (uranoplasty),  and  a  descrip- 
tion of  many  dififerent  operations  and  modifications,  typical  and 
atypical,  are  too  long  for  the  allotted  space  in  this  volume,  nor  can 
I  hope  to  credit  to  its  originator  each  method  or  step.  Staphylor- 
rhaphy, according  to  Verneuil,  has  been  invented  four  dift'erent 
times ;  and  it  is  probable  that  nearly  every  modification  and  every 
step  of  staphylorrhaphy  and  uranorrhaphy  have  been  invented  over 
and  over  again  by  ingenious  operators  to  meet  the  necessities  which 
they  encountered.  I  shall  only  present  a  few  methods  and  principles 
which  are  applicable  in  most  cases,  gathered  from  various  sources  by 
observation  of  a  number  of  skillful  operators  and  their  methods  and 
results,  and  then  tested  out  in  practice  to  my  own  satisfaction. 

Hare-lip  Operation  (Cheiloplasty). — Usually  the  patient  is 
placed  in  Roser's  position ;  that  is,  lying  on  the  back,  with  the  head 


^10 


SURGICAL    DISEASES    OF    CHILDREN 


hanging  over  the  end  of  the  table.  This  position  brings  the  anterior 
nares  at  a  lower  level  than  the  entrance  to  the  larynx,  and  so 
avoids  the  danger  of  the  aspiration  of  blood  into  the  trachea.  The 
surgeon  sits  opposite  the  patient's  head  and  face,  which  are  inverted 
before  him.     Some  surgeons  prefer  to  stand  at  the  patient's  right 


C5  ..O 


Fig.    253. 


Fig.  254. 


c:^.c:^ 


Fig.  255. 


Fig.  256. 


Fig.  257. 


Fig.  258. 


Figs.  253  to  258  illustrate  various  operations  for  single  and  double 
HARE-LIP.  Figs.  253  and  254  show  the  method  of  Nelaton;  255  and  256, 
that  of  Malgaigne;  257  and  258,  that  of  Mirault. 


shoulder  and  lean  over  the  face,  or,  instead  of  having  the  head 
hanging  so  far  over  the  end  of  the  table,  they  turn  it  to  the  right 
side,  so  that  the  blood  will  run  out  of  the  mouth  or  be  easily 
swabbed  out.  One  has  sometimes  operated  upon  infants  held  sit- 
ting upright. 

Anesthesia. — General  anesthesia  is,  of  course,  necessary,  ex- 
cepting in  very  young  infants  with  a  small  cleft  in  the  lip  it  is  not 
indispensable.  The  majority  of  surgeons  probably  prefer  chloro- 
form for  this  operation,  though  some  use  ether.  An  ordinary 
inhaler  may  be  used,  but  is  much  in  the  way  of  the  operator.     A 


MOUTH,   TONGUE,    FACE   AND    NECK 


7" 


Junker  inhaler,  having  the  end  of  the  rubber  tube  supphed  with  a 
bent  metal  canula,  which  delivers  the  vapor  into  the  angle  of  the 
patient's  mouth,  is  a  convenient  arrangement. 

Principles  of  CJieiloplasty  and  Points  in  Technique, — Careful 


Fig.  259. 


Fig.  260. 


Fig.  261. 


Fig.  262. 


Fig.  263. 


Fig.  264. 


Figs.  259  to  264.  Diagrams  of  various  operations  for  single  and  double 
HARE-LIP.  Figs.  259  and  260  show  the  operation  of  Giraldes;  263  and 
264,  that  of  Maas. 

antiseptic  preparation  is  essential.  A  good  deal  of  blood  can  be 
saved  by  passing  temporary  ligatures  through  the  lip,  one  on  each 
side,  to  include  the  coronary  artery.  These  are  removed  on  com- 
pletion of  the  operation.  Forceps  are  inefficient,  and  the  fingers  of 
most  assistants  are  in  the  way.  The  edges  of  the  cleft  are  to  be 
freshened  so  that,  when  sutured,  union  can  take  place.  No  tissue 
should  be  wasted,  yet  the  margins  must  be  pared  sufficiently  with 
knife  or  scissors.  These  edges  or  flaps  are  to  be  so  contrived 
that  when  brought  together  they  fit  and  are  of  equal  length.  The 
lip  at  the  suture  line  must  project  beyond  its  normal  level  to  allow 
for  contraction  of  the  scar.     When  the  edges  of  the  cleft  are  thin 


712  SURGICAL    DISEASES    OF    CHILDREN 

the  raw  surface  for  approximation  can  be  increased  by  cutting  only- 
part  way  through  the  thickness  of  the  Hp  and  turning  the  margin 
inward,  or  sometimes  by  cutting  the  edges  on  the  bevel.  All  of  the 
red  margin  of  the  cleft  is  to  be  disposed  of  in  the  paring.  When 
the  cleft  extends  into  the  nostril  or  the  nostril  is  deformed,  the 
cutting  must  also  extend  into  the  nostril,  so  as  to  correct  it.  (These 
points  are  illustrated  in  Figs.  253  to  264.)  There  must  be  no  ten- 
sion on  the  flaps,  consequently  they  must  be  freely  loosened  from 
their  attachment.  To  do  this  the  lip  is  everted  and  its  mucous 
membrane  incised  where  it  joins  the  alveolar  process.  Through 
this  incision  the  soft  parts  are  divided  near  the  bony  surface  and 
separated  from  the  bone  a  distance  of  three  or  four  times  the  width 
of  the  cleft.  If  the  central  part  of  the  lip  below  the  septum  nasi 
is  to  be  moved,  this,  too,  must  be  loosened  from  the  bone  beneath. 
If  the  intermaxillary  bone  project,  it  must  be  pushed  back  into  its 
place,  its  margin  and  that  of  the  maxillary  freshened  and  one  or 
more  sutures  passed  to  unite  them,  the  sutures  being  tied  or  twisted 
upon  the  inside.  If  the  intermaxillary  is  too  stiff  to  be  pushed 
into  place  a  wedge-shaped  piece  may  be  removed  from  its  inner 
.surface,  without  interfering  with  the  teeth  not  yet  erupted.  The 
intermaxillary  should  never  be  removed.  The  freshened  edges  of 
the  flaps  must  be  brought  together  and  held  together  by  sutures 
until  healing  is  complete.  In  bringing  together  the  flaps  it  is 
essential  that  the  marginal  line  of  the  muco-cutaneous  junction  be 
accurately  adjusted.  (See  Fig.  246,)  Another  important  point  is 
in  bringing  up  the  ala  of  the  nostril  to  the  right  size  and  position. 
(Compare  Figs.  248  and  249,  and  also  Figs.  250  and  251.)  With- 
out attention  to  these  two  points  and  free  loosening  of  the  flaps  to 
prevent  tension,  all  other  efforts  will  be  in  vain. 

Suture  with  the  hare-lip  pin  is  obsolete.  Some  operators  prefer 
silver  wire.  With  others,  silk,  silkworm  gut,  or  horsehair  are  in 
favor.  In  my  own  work  I  want  at  least  one  silver  wire  or  aluminum 
bronze  suture,  shotted,  for  the  nose,  one  shot  being  placed  in  the 
groove  just  outside  the  ala,  and  the  other  inside  the  opposite  nos- 
tril. Silkworm  gut  and  horsehair  are  ideal  materials  for  the  other 
sutures.  There  should  be  one  or  two  strong  ones  placed  at  some 
distance  from  the  margins,  rather  as  retaining  sutures,  and  fine 
ones  close  together  between,  acting  as  coaptation  sutures.  It  is  well 
to  pass  the  strongest  retaining  sutures  from  the  under  side  of  the  lip 
and  tie  them  there.  Usually  one  suture  is  so  placed  as  to  control 
the  hemorrhage.  The  fine  sutures  are  placed  upon  the  outside. 
Some  surgeons  unite  the  inner  margins  with  catgut  or  silk  first, 
then  pass  strong  retaining  sutures  and  fine  sutures  between  these 
from  the  outside.  As  to  dressings,  some  surgeons  still  adhere  to  the 
plan  of  passing  adhesive  straps  transversely  across  the  line  of  union, 


MOUTH,   TONGUE,    FACE   AND    NECK 


713 


their  ends  extending  back  toward  the  ears.  Some  cross  two  ad- 
hesive straps  upon  the  wound  (having-  a  few  layers  of  gauze 
beneath),  their  ends  diverging  upon  the  cheeks.  Some  use  no 
dressing  at  all,  leaving  the  wound  entirely  open.  One  prefers  to  pro- 
tect the  wound  with  a  bit  of 
silk  crape,  fastened  with  col- 
lodion at  either  end,  as  the 
fashion  is  at  the  Boston  Chil- 
dren's Hospital ;  or  with  a  mild 
antiseptic  powder,  which  forms 
a  crust. 

Strapping  across  the  wound 
is  apt  to  press  too  hard.  Yet 
I  think  strapping  which  does 
not  touch  the  wound  is  useful 
to  aid  in  immobilizing  the  face. 
A  strap  on  either  side  may  pass 
upward  diagonally  across  the 
cheeks,  crossing  each  other 
upon  the  bridge  of  the  nose 
and  extending  on  to  the  fore- 
head. Or  they  may  start 
straight  up  on  the  cheeks 
toward  the  eyes,  and  then  be 
turned  inward  to  the  nose  and  crossed  on  their  way  to  the  forehead, 
as  Ferguson,  of  Chicago,  places  them.  The  patient's  arms  should  be 
so  restrained  that  touching  the  wound  is  impossible  for  him.  Vomit- 
ing, laughing,  or  crying  should  be  avoided  if  possible.  The  patient 
should  be  fed  with  a  dropper  or  spoon.  A  babe  should  not  be 
allowed  to  suck,  nor  any  patient  to  masticate. 

The  wound  should  be  undisturbed  for  thirty-six  or  forty-eight 
hours.  If  any  of  the  sutures  upon  the  skin  surface  can  be  spared 
at  the  end  of  that  time  they  should  be  removed  and  will  leave  no 
scars.  Those  passed  from  beneath  the  lip  may  be  left  until  firm 
union  is  complete. 

There  are  a  thousand  and  one  methods  of  planning  the  flaps. 
The  few  that  are  shown  in  diagram  will  serve  admirably  in  most 
cases ;  or  will  illustrate  the  principles  which  the  surgeon  may  readily 
adapt  to  special  cases. 

Urano-staphylorrhaphy.  (See  Figs.  265  and  266.) — The  patient 
is  anesthetized  with  chloroform  or  ether  and  placed  in  Roser's  posi- 
tion. The  surgeon  sits  or  stands,  according  to  the  height  of  the 
operating  table,  opposite  to  the  patient's  head,  which  must  be  held 
by  an  assistant.  A  good  light  shining  into  the  mouth  is  indis- 
pensable.   If  there  is  any  possible  chance  of  daylight  waning  before 


Fig.  265.  Urano-staphylorrhaphy. 
Dotted  lines  mark  freshened  edges 
and  incisions. 


714 


SURGICAL    DISEASES    OF    CHILDREN 


the  operation  is  completed,  an  adjustable  artificial  light  must  be  at 
hand.  The  gag  is  introduced.  There  are  numerous  kinds  of  gags, 
some  of  them  very  ingenious.  The  complicated  special  gags  are  not 
indispensable.  One  can  use  a  simple  gag  and  hold  the  tongue  by  a 
suture  passed  through  its  tip.  Besides  the  anesthetist  there 
should  be  an  assistant  to  sponge  and  a  nurse  to  hand  sponges. 
Many  dozens  of  "  small  gauze  "  to  be  used  as  stick  sponges — that 
is,  fastened  on  sponge  holders  or  hemostats — should  be  in  readiness. 
There  is  sure  to  be  blood  flowing,  and  it  must  be  kept  out  of  the 
larynx  and  out  of  the  way  of  the  operator.     The  tissues,  which 

should  for  several  days  previ- 
ously have  received  attention  in 
the  way  of  antiseptic  cleansing, 
are  now  sponged  with  alcohol. 
Next,  each  half  of  the  uvula, 
at  its  tip,  is  transfixed  with  a 
silk  suture,  which  is  tied  in  a 
loop  and  serves  to  hold  the  soft 
palate  much  better  than  tissue 
forceps ;  though  some  operators 
use  a  forceps.  The  edges  of  the 
cleft  are  now  pared  with  a  very 
sharp  and  very  thin-bladed 
knife.  The  strip  from  the  mar- 
gin should,  if  possible,  be  kept 
in  one  continuous  piece,  for  the 
purpose  of  making  sure  that  the 
freshening  of  the  edges  is  com- 
plete. The  strip  of  margin  ex- 
tends from  the  half-uvula  on 
one  side  forward  to  and  around  the  angle,  if  it  end  in  an  angle  in 
front,  and  back  on  the  other  side  to  the  tip  of  the  half-uvula,  and 
the  bridle  of  mucous  membrane  is  left  attached  and  held  up  out  of 
the  way.  These  points,  excepting  the  complete  denudation,  are  not 
indispensable,  but  they  are  convenient. 

There  will  be  considerable  bleeding  from  the  cut  margins,  which 
the  assistant  should  dextrously  stanch  as  best  he  may  without  get- 
ting his  sponge  in  the  way  of  the  operator.  If  the  margins  of 
the  cleft  are  very  thin  the  operator  may  choose  to  split  it  rather 
than  to  remove  any.  The  next  step  is  the  loosening  of  the  muco- 
periosteal  flaps  from  the  roof  of  the  mouth  at  each  side.  Here  dif- 
ferent surgeons  differ  in  their  technique.  Some  cut  the  edge  of 
the  flap  loose  along  the  freshened  margin  of  the  cleft  and  intro- 
duce the  elevator  there  and  work  outward  toward  the  alveolar  pro- 
cess, separating  the  periosteum  from  the  bone  and  pulling  down 


Fig.  266.  Urano-staphylorrhaphy. 
Flaps  approximated  and  sutured. 


MOUTH,    TONGUE,    FACE    AND    NECK 


715 


(i.  e.,  from  the  roof  of  the  mouth)  the  flaps,  and  only  make  side 
incisions  to  relieve  tension  after  the  flaps  are  loosened,  or  even 
after  the  sutures  are  passed.  Others  first  make  the  side  incisions, 
which  extend  from  opposite  the  last  molar,  parallel  to  and  just 
within  the  alveolar  process,  forward  as  far  as  appears  necessary. 
Through  this  incision  a  periosteal  elevator  or  blunt  dissector  is 
thrust,  and  the  muco-periosteal  flap  separated  from  ihe  bone,  work- 
ing toward  the  middle  line.  As  to  the  order  in  which  these  steps 
should  be  executed  I  find 
that,  w^orking  with  ordi- 
nary instruments  with 
which  a  general  surgeon 
is  apt  to  be  provided,  it 
is  better  to  make  the  lat- 
eral incisions  first  and 
work  through  them  to- 
ward the  middle  line.  But 
wdien  provided  with  spe- 
cial cutting  and  elevating 
instruments,  set  at  nearly 
right  angles  to  their 
handles,  it  is  better  to 
begin  at  the  margin  of 
the  cleft  and  work  out- 
ward; for  until  the  flaps 
have  been  loosened  and 
an  attempt  made  to  bring 
them  together,  it  is  im- 
possible to  tell  just  how 
long  the  lateral  incisions 
need  be  to  relieve  tension. 
Flaps  from  a  high  Gothic  pic.  267.  Hare-lip  and  wide  cleft  of 
arch  come  together  much  hard  and  soft  palate.     The  nostril  is 

better  than  those    from   a  deformed,    and    opens    into    the    mouth 

,        -.^  just  above  the  alveolar  process.     White- 

low  JNorman  arch.  During  head   gag   in   position.     Author   usually 

the  loosening  of  the  flaps,  prefers   an  ordinary  gag. 

hemorrhage  will  be  free  and  should  be  checked  by  pressure. 

After  the  flaps  are  prepared  comes  the  suturing.  Here  again 
is  a  diversity  in  practice,  both  in  regard  to  suture  material  and  the 
method  of  its  use.  G.  V.  I.  Brown  uses  aluminum-bronze  wire  and 
buttons  of  pure  silver  as  retention  sutures.  The  double  wire  is 
threaded  into  the  button  and  the  perforated  shot,  four  in  a  bunch, 
prepared  before  the  operation  is  begun.  One  or  two  of  these  dou- 
ble-wired button  sutures  are  used  as  retaining  sutures,  and  the 
e  ges  coapted  with  chromicized  or  formalinized  catgut.     Some  use 


7i6 


SURGICAL    DISEASES    OF    CHILDREN 


buttons  of  celluloid  or  ordinary  agate  buttons,  and  they  either 
twist  the  wires  or  shot  them.  Some  use  horsehair,  which,  however, 
like  any  other  suture  that  must  be  tied,  cannot  be  used  rapidly  in 
the  mouth.    Some  pass  the  needle  from  the  mucous  side  and  some 

.-,  from  the  periosteal  side. 
Like  many  other  sur- 
geons, I  prefer  well 
anealed  fine  silver  wire ; 
and  can  place  the  sutures 
more  accurately  and 
rapidly  with  very  little 
handling  of  the  tissues 
by  means  of  a  Reverdin 
needle  passed  from  the 
mucous  toward  the  peri- 
osteal side  of  the  flap ; 
and  twist  them  more 
conveniently  with  a 
plain  "  S  "  wire  twister 
than  with  forceps. 
Usually  all  the  sutures 
are  placed  before  any 
are  fastened. 

The  sutures  being 
placed,  if  the  margins 
of  the  flaps  come  to- 
gether without  tension, 
they  may  be  tied  or 
twisted  at  once.  If  not, 
it  may  be  necessary  at 
this  stage  to  divide  the 
muscular  attachments  of 
the  soft  palate.  This 
can  be  done  by  reaching 
throupfh  the  lateral  incis- 


FiG.  268.  Same  case  as  267.  Two  oper- 
ations have  been  done.  The  hard  and 
soft  palate  were  completely  closed  at 
one  operation,  and  the  lip  and  nostril 
at  another,  later.  The  nose  is  not  yet 
quite  symmetrical ;  and  the  left  central 
incisor  tooth  should  be  turned  in  its 
socket  by  a  dentist ;  but  the  patient  is 
satisfied  and  declines  further  improve- 
ment. 

ion  with  knife  or  scissors.  But  frequently,  if  an  incision  parallel 
with  the  outer  side  of  the  alveolar  process  extend  backward  from 
behind  the  last  molar,  a  blunt  dissector  or  the  finger  can  be  thrust 
through  it  and  the  soft  parts  loosened  up  so  freely  that  no  further 
cutting  will  be  necessary.  C.  H.  Mayo  passes  a  tape  through  the 
lateral  incisions  and  around  both  flaps,  drawing  them  together  and 
preventing  tension  on  the  sutures  until  union  takes  place.  The  tape 
also  affords  drainage  for  the  space  above  the  flaps.  This,  how- 
ever, some  think  a  disadvantage  rather  than  an  advantage,  as  dis- 
charges from  the  nose  come  into  the  mouth.  The  tape  is  not 
necessary  if  the  flaps  hang  perfectly  flaccid,  as  they  should,  after 


MOUTH,    TONGUE,    FACE    AND    NECK 


717 


being  sutured.     Suture  ends  should  be  cut  short  and  turned  up  to 
avoid  irritating  the  tongue. 

After  Treatment. — The  after  treatment  is  very  important.  The 
child  should  be  given  a  coffee-saline  enema  and  be  put  to  bed.  (See 
Sections  on  Shock,  and  on  Management  After  Operation.)  Vomit- 
ing, laughing,  crying,  and  attempts  at  talking  should  be  avoided 
as  much  as  possible.  Foods  should  all  be  fluids  and  administered 
with  dropper  or  spoon, 
no  sucking  or  mastica- 
tion allowed.  The 
mouth  should  be  rinsed 
with  a  spoonful  of 
water  after  each  spoon- 
ful  of  food,  and 
cleansed  after  each  feed- 
ing either  with,  a  spray 
or  very  careful  use  of 
swabs  dipped  in  3  per 
cent,  dioxygen  or  other 
mild  inocuous  solution. 
The  nares,  also,  should 
be  cleansed. 

Prompt  union  may 
be  secured  along  the 
whole  suture  line.  (See 
Figs.  252  and  268.) 
But  even  if  it  gape  in 
places,  successful  clos- 
ure should  not  be  de- 
spaired of ;  the  flaps 
should  be  kept  in  appo- 
sition, and  healing  by 
granulation  or  adhesion 
of  granulating  surfaces 
may  close  the  gap.  If 
any  portion  fails  to  unite  it  is  apt  to  be  about  the  junction  of 
the  hard  and  soft  palates  (see  Fig.  269)  and  can  be  closed  by 
stimulating  granulation  or  by  a  slight  operation  subsequently. 
If  the  child  is  old  enough  to  talk,  as  soon  as  the  wound  has 
healed,  systematic  and  persistent  training  in  articulation  and 
intonation  should  be  given  him  by  an  experienced  teacher.  There 
are  numerous  other  methods  of  closing  palatal  clefts,  both  by  slid- 
ing flaps  and  by  chiseling  off  portions  of  the  palate  bones  or  the 
alveolar  processes  to  aid  in  the  formation  of  the  flaps,  and  by 
turning  and  sometimes  superimposing  flaps.  But,  so  far  as  possi- 
ble,  the   bony   structures   should   not  be   interfered   with   and   no 


Fig.  269.  This  case  was  originally  very 
similar  to  Fig.  267.  The  hard  and  soft 
palate  were  operated  at  one  sitting. 
The  pictures  show  a  very  common  re- 
sult, namely  union  with  the  exception 
that  an  opening  remains  at  about  the 
junction  of  hard  and  soft  palates.  This 
can  be  easily  closed. 


7i8  SURGICAL    DISEASES    OF    CHILDREN 

tissue  should  be  turned  out  of  its  natural  relation  to  oral  and  nasal 
cavities  and  to  bony  attachments.  Of  the  more  complicated  methods 
the  Davies-CoUey  is  perhaps  the  most  useful. 

MACROSTOMA 

Macrostoma  is  a  congenital  .enlargement  of  the  mouth.  The 
usual  form  is  produced  by  a  partial  failure  in  the  fusion  of  the 
superior  and  inferior  maxillary  processes.  Failure  of  union  between 
the  superior  maxillary  and  the  fronto-nasal  or  the  external  nasal  pro- 
cess may  take  place.  (See  remarks  on  Etiology  of  Hare-lip  and 
Cleft-Palate.)  The  malformation  is  usually  unilateral,  but  may  be 
bilateral.  It  is  more  frequent  in  girls  than  in  boys.  It  is  apt  to  be 
associated  with  hare-lip  or  with  branchial  fistulse,  or  supernumerary 
auricles,  or  malformation  of  the  auricle,  as  shown  in  Figs.  134 
and  135. 

Treatment. — The  condition  should  be  remedied  by  plastic  opera- 
tion, denuding  the  edges  of  the  fissure  and  uniting  them  by  sutures 
passed  inside  the  cheek,   or  subcutaneously,   or  both. 

MICROSTOMA  AND  ATRESIA  ORIS 

The  mouth  may  be  imperforate,  or  congenitally  too  small. 

Treatment. — In  the  former  case  plastic  operation  will  be  neces- 
sary, making  an  opening  of  suitable  size  by  transverse  incision. 
Also  in  the  latter  case  if  dilatation  does  not  succeed.  If  enlarged  by 
cutting  it  will  be  necessary  to  unite  the  mucous  membrane  to  the 
skin  to  make  the  lips,  and  especially  to  turn  membranous  flaps  into 
the  angles  of  the  mouth. 

CONGENITAL   ABSENCE    OR   MALFORMATION   OF   THE 

TONGUE 

Absence  of  the  tongue  may  occur,  but  is  an  extremely  rare 
deformity.  Occasionally  a  tongue  is  cleft,  or  tridented,  or  it  may 
lack  muscular  development  upon  one  side 

MACROGLOSSIA 

Enlargement  of  the  tongue  may  occur  as  a  result  of  lym- 
phangiectasis  (see  Chapter  on  Tumors),  and  may  so  interfere  with 
breathing  and  with  the  functions  of  that  organ  as  to  be  a  very 
serious  matter. 

Treatment. — Slighter  cases  may  be  treated  with  electrolosis. 
(See  Section  on  Nevus.)  The  dangers  of  injections  or  any  treat- 
ment liable  to  cause  increased  swelling  should  be  foreseen.  Pres- 
sure has  been  recommended,  but  is  hard  to  apply.    Astringents  are 


MOUTH,   TONGUE,    FACE   AND    NECK  7i9 

said  to  have  been  used  with  benefit,  but  are  superficial.  If  none  of 
these  succeed,  a  wedge-shaped  piece  of  the  tongue  may  be  removed 
and  the  sides  united;  or  a  portion  cut  off  with  the  hot  or  cold 
wire  ecraseur. 

PAPILLOMA,   NEVUS  AND   FIBROMA   OF  THE  TONGUE 

Various  tumors  may  occur  upon  the  tongue,  and  can  be  re- 
moved by  excision  or  by  galvano  cautery. 

CYSTS  BENEATH  THE  TONGUE 

Quite  a  variety  of  cystic  enlargements  may  take  place  beneath 
the  tongue  and  in  the  floor  of  the  mouth.  Of  these  will  be  men- 
tioned salivary  retention  cyst,  from  occlusion  of  the  sublingual 
salivary  gland,  which  seldom  occurs ;  mucous  retention  cyst,  caused 
by  obstruction  of  a  mucous  duct ;  ordinary  ranula ;  dermoid  cyst, 
filled  with  fluid,  sebaceous  matter  and  hair,  and  located  at  the  point 
of  junction  between  branchial  arches;  enlarged  bursse,  which,  as 
in  bursitis  elsewhere,  may  contain  melon-seed  bodies ;  and  congen- 
ital sublingual  cysts,  due  to  persistence  of  the  sublingual  duct.  Any 
of  these  are  likely  to  be  called  ranula,  but  that  name  is  only  prop- 
erly applied  to  the  first  two  varieties  mentioned,  of  which  the  sec- 
ond is  far  more  common.  Ranula,  caused  by  retention  of  mucus 
in  an  obstructed  duct,  is  a  bluish,  pearl-colored,  fluctuating,  trans- 
lucent painless  swelling  beneath  the  tongue.  It  may  be  marble-  or 
egg-sized  and  it  causes  no  symptoms  excepting  by  its  bulk.  If 
snipped  open  it  discharges  a  clear  viscid  fluid  like  egg-albumen,  and 
when  the  wound  heals  it  refills.  A  small  seton  of  silver  wire  may 
cause  its  disappearance.  Or  it  may  be  necessary  to  cut  away  a 
portion  of  its  wall  so  as  to  lay  it  freely  open,  and  cauterize  its 
lining  membrane  with  silver  nitrate  or  carbolic  acid,  removing 
any  excess  of  the  caustic. 

TONGUE  TIE 

The  surgeon  may  be  asked  to  inspect  quite  a  number  of  infants 
supposed  to  be  "  tongue  tied  "  before  he  finds  a  real  case  of  this 
malformation.  Yet  it  does  occur  that  the  frenum  linguae  is  so  short, 
or  attached  so  far  forward,  that  the  tongue  cannot  be  protruded  to 
the  lips,  or  even  beyond  the  alveolar  ridge. 

Treatment. — The  anterior  margin  of  the  frenum  should  be 
nicked — not  too  close  to  the  tongue,  nor  too  deeply,  lest  the  ranine 
arteries  be  injured — and  then  torn  back  with  the  finger  nail  until 
sufficiently  free,  but  not  too  free. 


720 


SURGICAL  DISEASES  OF  CHILDREN 


EPULIS 

Epulis  is  a  growth  located,  as  its  name  indicates,  upon  the 
gum.  It  may  be  fibrous  or  sarcomatous.  (See  also  Sections  on 
Fibroma  and  Sarcoma.) 

Fibrous  epulis  is  a  hard,  slow-growing  tumor  springing  from 
peridental  membrane.  It  is  covered  with  mucous  membrane  which 
is  not  very  dark  colored  unless  inflamed,  and  may  or  may  not  be 
ulcerated. 

Sarcomatous  epulis  grows  from  the  periosteum  of  the  alveolar 
ridge,  more  often  of  the  upper  jaw.  It  is  of  a  deeper  color  than 
the  fibrous  epulis. 

Treatment. — The  treatment  of  either  form  of  epulis  is  removal. 
If  malignancy  is  suspected  this  should  be  done  very  thoroughly, 
even  if  a  part  of  the  jaw  must  be  removed  with  the  tumor.  If 
thoroughly  removed  it  is  not  likely  to  recur.  Even  with  fibrous 
epulis  it  may  be  necessary  to  sacrifice  a  tooth,  the  growth  is  so 
close  to  or  springing  from  its  socket. 

FISTULiE  AND  CYSTS  OF  THE  NECK 

These  are  located  either  centrally  or  laterally.  The  former 
usually  originate  in  the  thyroglossal  duct;  the  latter  in  faulty  oblit- 
eration of  the  branchial  clefts  and  are  therefore  apt  to  appear  ex- 
ternally somewhere  along  the  anterior  margin  of  the  sterno-mas- 
toid  and  to  extend  upward  and  inward.  But  multilocular  branchio- 
genous  cysts  may  arise  anywhere  in  the  triangles  of  the  neck,  and 
their  exact  etiology  is  disputed.  Pharyngeal  and  esophageal  diverti- 
cula are  also  branchiogenous.  A  branchial  fistula  may  open  either 
internally  or  externally  or  both.  Its  deeper  portion  is  lined  with 
cylindrical  epithelium,  that  more  external  with  the  pavement  variety. 
A  portion  of  such  a  tract  being  occluded  may  become  a  cyst,  which, 
if  its  lining  membrane  be  cylindrical,  will  contain  a  seromucous  fluid 
and  be  called  a  hydrocele  of  the  neck.  Lying  deeply  it  may  appear 
also  within  the  mouth.  If  lined  with  pavement  epithelium  the  ac- 
cumulated contents  will  be  sebaceous  and  it  will  be  called  a  dermoid. 
Or  the  contents  may  contain  the  characteristics  of  both  varieties.  A 
fistula  usually  discharges.  A  cyst  slowly  grows  and  becomes  a 
more  or  less  fluctuating  painless  tumor.  There  is  a  variety  of  cyst 
of  the  neck  sometimes  called  multilocular  branchiogenous  cyst 
which  differs  somewhat  from  those  just  described  in  being  multi- 
locular and  often  multiple.  The  contents  are  serous.  These  tu- 
mors somewhat  resemble  cystic  lymphangioma  but  are  distinct  from 
hygroma  and  from  Berger's  polycystic  tumors  of  the  parathyroid.'- 

Branchial  cysts  may  become  malignant.     Either  cysts  or  fistu- 

1  Guide  pratique  de  chirurg.  Infantile,  E.  Estor,  p.  233  et  scq.    Estor 
and  Massabau :  Revue  de  Chirurgie,  Sept.,  1908. 


MOUTH,  TONGUE,  FACE  AND  NECK  721 

lous  tracts  are  liable  to  infection,  producing  inflammation.  In 
diagnosis,  lymphangioma,  lymphadenitis,  angioma,  hygroma  and 
sarcoma  must  be  excluded. 

Treatment. — The  cure  of  either  fistula  or  cyst  of  the  neck  is 
more  of  a  problem  than  might  at  first  appear.  Shallow  fistulse  may 
sometimes  be  closed  by  destroying  the  lining  with  the  galvano- 
cautery.  Tincture  of  iodine  or.  solution  of  silver  nitrate  may  be 
used  similarly.  Unilocular  cysts  may  be  treated  in  the  same  way 
after  evacuating  their  contents,  but  the  method  is  tedious  and  un- 
certain. The  only  certain  way  is  to  dissect  out  the  fistula  or  cyst, 
removing  every  portion  of  its  lining  wall.  This  may  be  difficult, 
leading  to  the  pharynx  or  tonsil  or  carotid  region  in  the  branchial, 
or  behind  the  larynx  and  thyroid  in  the  thyrohyoid  varieties.  A 
fistula  should  first  be  injected  with  methylin  blue  and  then  a  probe 
introduced,  thus  furnishing  guides  by  which  the  dissection  may  be 
made.  If  pharynx  or  esophagus  are  opened,  they  must  be  securely 
sutured.  (61.)  The  deeper  portions  of  the  wound  are  approxi- 
mated with  catgut.  A  slender  drain  should  be  placed,  to  be  left 
forty-eight  hours.  The  flaps  of  skin  and  fascia  are  closed  with  sub- 
cuticular suture  of  silkworm  gut.  Rectal  feeding  should  be  used 
for  some  days.  Fistulae  of  the  neck  may  be  accompanied  by  super- 
numerary auricles,  see  Appendix  (62). 

COLOBOMA  OF  THE  EYELID 

This  is  a  congenital  malformation  consisting  in  a  cleft  or  fissure, 
usually  of  the  upper  eyelid.  It  is  sometimes  associated  with  hare- 
lip, cleft-palate  and  with  coloboma  of  the  iris  and  choroid,  and 
occasionally  accompanied  by  dermoid  of  the  cornea. 

Treatment. — The  edges  of  the  cleft  should  be  pared  and  united 
with  fine  sutures  of  horsehair  or  silk  passed  through  skin  and 
cartilage. 

EPICANTHUS 

Epicanthus  is  a  congenital  malformation  in  which  a  crescentic 
fold  of  redundant  skin,  with  the  concavity  of  the  crescent  toward 
the  eye,  extends  from  the  inner  end  of  the  eyebrow  down  across 
the  canthus.  It  is  usually  bilateral,  apt  to  be  hereditary,  and  to  be 
accompanied  by  a  flat  nose,  and  sometimes  by  other  defects  of  the 
adnexa  or  of  the  eyes  themselves. 

Treatment. — The  appearance  of  the  eyes,  and  also  of  the  wide 
and  flat  bridge  of  the  nose,  can  be  improved  by  a  small  but  neat 
operation.  A  small  ellipse  of  skin,  with  its  long  diameter  vertical, 
should  be  removed  from  the  middle  of  the  bridge  of  the  nose.  The 
folds  of  skin  adjacent  to  the  ellipse  should  be  freely  loosened  in  the 
direction  of  the  canthi,  so  that  when  the  margins  of  the  ellipse  are 
united  by  suture  in  the  middle  line  the  overhanging  skin  is  drawn 
away  from  the  eyes. 


CHAPTER  XXVI 

CLUBFOOT  AND  SOME  OTHER  DEFORMITIES  OF 
THE  EXTREMITIES 

Clubfoot — Weak  Ankles — Clubhand — Supernumerary  Arms 
OR  Legs,  Hands  or  Feet — Supernumerary  Digits  (Poly- 
dactylism) — Intra-Uterine  Amputations  and  Constric- 
tions AND  Suppression  of  Intermediate  Parts,  Absence  of 
Parts — Webbed  Fingers  or  Toes  (Syndactylism) — Irreg- 
ular Alignment  of  Digits — Malformations  of  Joints. 

CLUBFOOT 

Clubfoot  (Talipes,  Pes  Varus,  Pes-contortus)  may  be  either 
congenital  or  acquired.  It  is  an  abnormal  position  of  the  foot  with 
relation  to  the  leg,  and  usually  also  of  the  pes  or  anterior  portion 
of  the  foot  with  relation  to  the  talus  or  ankle  portion.  The  altered 
positions  are  either  in  the  upward  or  downward,  inward  or  out- 
ward directions,  or  in  combinations  of  these.  The  deviation  takes 
place  in  the  ankle  joint  or  in  the  medio-tarsal  joint,  i.  e.,  between 
the  os-calcis  and  astragalus  behind,  and  the  cuboid  and  scaphoid 
in  front.  One  should  remember  that  the  foot  has  two  arches, 
an  antero-posterior  and  a  transverse,  the  articulating  surface 
of  the  astragalus  being  the  apex  of  both  arches,  that  the  bones 
composing  these  arches  are  maintained  in  position  by  ligaments, 
fasciae  and  the  tonicity  of  muscles. 

There  is  also  to  be  considered  the  cartilaginous,  unossified  con- 
dition of  the  bones,  the  softness  and  weakness  of  muscles,  fasciae, 
and  ligaments,  and  the  abundance  of  plantar  and  subcutaneous  fat 
in  the  infant  and  child  as  compared  with  the  adult.  The  bony 
arch  does  not  begin  to  form  in  the  infant  until  after  the  first  year, 
but  the  cartilages  are  somewhat  supported  below  by  fat. 

Etiology. — The  etiology  of  congenital  clubfoot  is  in  many  cases 
unsatisfactory.  (See  Section  on  Malformations.)  That  of  the 
acquired  forms  will  be  referred  to  in  the  description  of  the  special 
variety. 

Varieties. — Of  clubfoot  there  are  four  principal  varieties, 
sometimes  called  the  simple  forms.,  viz..  Talipes  varus,  in  which 
the  foot  is  turned  inward ;  talipes  valgus,  in  which  the  foot  is  turned 
outward ;  talipes  equinus,   in  which  the  toes  are  held   downward 

722 


CLUBFOOT   AND    SO^IE    OTHER    DEFORMITIES 


723 


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724 


SURGICAL    DISEASES    OF    CHILDREN 


up  to  the  present  shows  the  greatest  diversity  of  opinions,  which 
and  the  heel  elevated;  and  talipes  calcaneus,  in  which  the  toes  are 
elevated  and  the  heel  depressed.  Besides  these  are  talipes  cavus,  in 
which  the  antero-posterior  arch  is  exagerated,  and  talipes  planus, 
in  which  it  is  somewhat  flattened.  The  compound  forms  are  com- 
binations of  the  others,  and  are  named  accordingly,  for  instance 
equino-varus,  calcaneo-valgus,  et  cetera.  The  most  common  va- 
riety is  a  compound 
one,  equino-varus ;  that 
next  in  frequency,  cal- 
caneo-valgus. 

Talipes  varus. — ■ 
This  malformation  in  a 
very  mild  degree  is 
often  observed  in  the 
new-born,  and  alarms 
mothers,  but  soon  cor- 
rects itself.  In  the 
pathological  degree  it 
is  very  rare  in  the 
simple  form,  being  a 
bending  inward  of  the 
pes,  the  sole  usually 
facing  somewhat  back- 
ward. (Figs.  270,  271, 
272,  also  Figs.  277, 
278,  279.)  In  combina- 
tion with  equinus  it 
forms  the  most  common  variety  of  clubfoot. 

Talipes-valgus. — A'algus,  in  which  the  foot  turns  outward 
and  the  scaphoid  and  astragalus  project  on  the  inner  side,  while  not 
common  as  a  congenital  deformity,  is  more  common  than  varus. 
(Figs.  273,  274,  287.)  In  its  acquired  form  it  is  common. 
Acquired  valgus  is  classified  as  rachitic,  paralytic,  static  and  trau- 
matic. Rachitic  valgus  is  very  common  in  children  and  frequently 
accompanied  by  knock-knee  and  anterior  bowing  of  the  tibia. 
Paralytic  valgus  is  common,  due  generally  to  poliomyelitis.  Static 
valgus,  due  to  weight-bearing  on  a  weak  arch,  is  not  so  common  in 
childhood  as  in  adolescence,  yet  is  sometimes  met,  usually  in  con- 
nection with  weak  ankles  in  overgrown  youths  of  feeble  muscula- 
ture, especially  girls  such  as  have  lateral  curvature  of  the  spine. 
(Fig.  288.) 

Talipes  equinus. — Congenital  equinus  unassociated  with 
varus  is  seldom  met.  The  majority  of  the  cases  are  acquired,  fol- 
lowing spastic  paralysis,  pseudo-hypertrophic  muscular  paralysis, 
and  infantile  paralysis,  or  traumatism. 


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Fig.  276.  Pes  planus  or  flat  foot.  Note 
the  outward  curve  of  the  tendo-Achillis, 
seen  best  in  the  left  foot. 


CLUBFOOT   AND    SO.ME   OTHER    DEFORMITIES  725 


Fig.   273.     Talipes   equixo-varus   of  the   left   foot   and   valgus    of   right   in 
same   child.    An   unusual   association. 


Fig.   274.      Same  case   as   273,   different  view. 


Fig.   275.      Same   as    Figs.   273   and   274,   after   treatment  by  tenotomies  and 

plaster   bandages. 


726 


SURGICAL    DISEASES    OF    CHILDREN 


Talipes   calcaneus. — Calcaneus   is   rare   as  a   congenital   de- 
formity, being  almost  always  a  result  of  poliomyelitis. 

Pes  cavus. — This  may  be  either  congenital  or  acquired,  bat  is 


Fig.  277.    Double  talipes  varus.    Anterior  view,  see  also  Figs.  278  and  279 


Fig.  278.    Same  as  Fig.  277.    Posterior  view.    Referred  by  Dr.  L.  H.  Wagner. 


usually  acquired.  Cavus  is  an  exaggeration  of  the  aich  of  the  foot. 
When  congenital  it  is  seldom  alone,  but  usually  associated  with 
equino-varus.  When  acquired  it  results  from  paralysis,  with  con- 
tractions of  the  tibialis  anticus.  peroneus  longus,  and  the  plantar 
fascia. 

Pes  planus. — In  planus,  or  flatfoot,  the  arch  is  lowered  b) 


CLUBFOOT    AND    SOME    OTHER    DEFORMITIES  727 

lengthening  of  the  plantar  ligaments  and  relaxation  of  muscles.  It 
differs  from  valgus  only  in  that  the  foot  is  not  everted,  f  Fig.  276.) 
Talipes  equino-varus. — This  is  the  most  common  and  most 
typical  of  all  the  varieties  of  congenital  clubfoot,  and  may  also  be 
acquired.  The  deformity  involves  the  muscles,  ligaments,  fasciae 
and  bones  of  the  foot.  The  tendo-Achillis  and  the  tibialis  posticus 
and  anticus,  the  short  muscles  of  the  sole  and  the  flexors  of  the  toes 


Fig.  279.     Same  case  as  Figs.  2TJ  and  278  after  treatment  by  tenotomies 
and   plaster  bandages. 

are  contracted.  The  posterior  ligament  of  the  ankle,  the  anterior 
part  of  the  internal  lateral  ligament,  and  those  between  the  astragalus 
and  scaphoid  and  on  the  inferior  surface  of  the  calcaneus  and 
scaphoid  as  well  as  the  plantar  ligaments  and  fascise  are  short. 
Thus  the  foot  is  held  in  a  distorted  position  with  the  heel  elevated 
and  the  anterior  part  of  the  foot  adducted  and  rotated  with  its  inner 
side  forward  and  upward.  (Figs.  280  and  281,  282,  283  and  284.) 
The  greater  part  of  the  adduction  and  rotation  takes  part  at  the 
medio-tarsal  joint.  The  heel  is  dwarfed.  The  astragalus  projects 
on  the  dorsum  of  the  foot.  The  scaphoid  articulates  with  the  inner 
side  instead  of  the  anterior  surface  of  the  deformed  astragalus 
and  may  even  articulate  with  the  tibia.  The  cuboid,  the  cuneiform, 
and  the  metatarsals  are  rotated  inward,  and  so  retracted  upon 
their  under  surfaces  as  to  produce  more  or  less  cavus.  The  tendo- 
Achillis  lies  near  the  internal  malleolus,  and  the  fibula  may  be  drawn 
quite  behind  the  tibia.  Bursae  are  found  upon  the  convex  side  of 
the  foot ;  and  in  children  who  have  walked,  calloused  areas.  The 
overstretched  muscles  are  atrophied  but  not  paralyzed. 

Acquired  equino-varus. — In  the  acquired  form  the  condition, 
if  of  long  standing,  is  much  the  same  as  in  the  congenital,  but  when 


728 


SURGICAL    DISEASES    OF    CHILDREN 


the  result  of  poliomyelitis,  the  overstretched  muscles,  and  sometimes 
the  whole  extremity,  are  paralyzed  as  well  as  atrophied. 

Talipes  calcaneo-valgus. — This  may  be  congenital  or  ac- 
quired, and  like  the  other  and  more  unusual  compound  forms,  needs 
no  special  description. 

Prognosis. — The  prognosis  in  congenital  clubfoot  is  good.  One 
cannot  always  be  sure  that  the  growth  of  the  deformed  foot,  or  even 
of  the  leg,  will  keep  pace  with  that  of  its  fellow,  for  in  some  cases 
not  paralyzed,  there  seems  to  be  a  fault  with  the  trophic  centers  or 
for  some  reason  normal  growth  does  not  take  place.  But  the  de- 
formity can  always  be  cor- 
rected in  from  a  few  weeks  to 
a  few  months  or  a  year,  and 
will  remain  corrected  if  prop- 
erly managed.  The  paralytic 
cases  are  not  promising  as  a 
class,  but  sometimes  much 
can  be  done  for  them. 

Treatment. — One  can  easily 
recollect  when  the  treatment 
of  clubfoot  was  almost  en- 
tirely by  mechanical  means. 
It  was  sought  by  shoe-like 
appliances  of  various  forms 
to  which  levers  or  screws 
were  attached,  to  use  con- 
siderable pressure  and  grad- 
ually force  the  foot  into  cor- 
rect position  and  to  hold  it  there  until  it  would  stay  of  its  own 
accord.  This  often  required  months  and  years  of  persistent  and 
oft-repeated  attention,  and  then  sometimes  failed  to  accomplish 
its  purpose.  That  plan  is  still  used  for  mild  cases  taken  in  hand 
soon  after  birth.  But  for  the  more  marked  cases  and  those  com- 
ing to  the  surgeon  later,  there  is  a  better  method.  By  operation 
or  mechanical  force  the  deformity  of  the  foot  is  corrected  or  even 
over-corrected  at  once,  and  then  apparatus  is  used  of  which  only 
slight  pressure  is  required  to  maintain  the  proper  position  until  it 
becomes  natural.  This  can  be  accomplished  with  far  greater  cer- 
tainty, less  discomfort,  and  less  time  than  by  the  old  method. 

To  illustrate  this  method  the  treatment  of  equino-varus  will  be 
first  described  ;  and  then  the  same  principles  applied  to  other  varieties. 
Treatment  of  equino-varus. — The  sooner  after  birth  the  case 
comes  to  the  surgeon  and  treatment  begins  the  better.  The  resist- 
ance of  tissues  to  correction  is  tested  by  the  hands  of  the  surgeon. 
If  the  foot  can  be  easily  placed  in  correct  position  it  is  probable  that 


Fig.    280.     Talipes    equino-varus. 


CLUBFOOT    AND    SOME    OTHER    DEFORMITIES  729 

no  operation  will  be  necessary.  By  the  use  of  mechanical  means 
alone  the  foot  can  be  held  in  over-corrected  position  for  a  sufficient 
length  of  time  and  it  will  remain  permanently  corrected.  A  con- 
venient means  of  maintaining  correct  position  of  very  mild  club- 
foot in  new-born  babes  is  a  splint  made  of  strips  of  tin,  of  about  the 
width  of  the  foot  and  of  the  length  of  the  foot  and  leg.  Enough 
strips  of  tin  are  fastened  together  with  adhesive  plaster  to  make  a 
splint  of  convenient  stiffness.     This  is  bent  to  proper  shape  and 


Fig.  281.     Double  talipes  equino-varus. 

bandaged  to  the  foot,  holding  it  in  over-corrected  position.  The 
splint  is  removed  and  replaced,  the  foot  being  massaged  and  manipu- 
lated by  the  nurse  twice  daily,  and  a  cure  soon  effected.  Other 
cases  will  do  better  with  the  gypsum  bandage,  covering  the  foot  all 
but  the  toes,  and  extending  the  bandage  half  way  to  the  knee,  the 
foot  being  held  in  over-correction  while  the  bandage  is  applied  and 
allowed  to  harden.  A  new  bandage  is  applied  once  in  a  week  or 
two  or  three  weeks  as  necessary.  If  the  deformity  cannot  be  over- 
come easily  by  the  surgeon's  hands,  the  resisting  tendons  and  per- 
haps fascia  should  be  divided.  (See  Sections  on  Operations  on  Ten- 
dons, Subcutaneous  Tenotomy,  Open  Tenotomy.)  It  will  be  neces- 
sary to  tenotomize  the  tendo-Achillis,  probably  the  tibialis  posticus 
and  perhaps  the  anticus  and  the  plantar  fascia.  • 

The  tibialis  anticus  tendon  is  usually  felt  at  the  bottom  of  the 
concavity  at  the  inner  side  of  the  foot,  and  is  cut  near  its  insertion 
into  the  cuneiform.  The  tenotome  may  be  passed  beneath  it  or  cut 
down  upon  it. 

The  tendon  of  the  tibialis  posticus  is  a  little  more  troublesome 
to  find  in  a  fat  infant.  It  may  necessitate  an  open  wound  at  the  pos- 
terior border  of  the  tibia  just  above  the  internal  malleolus,  where 


730 


SURGICAL    DISEASES    OF    CHILDREN 


it  can  be  lifted  with  a  hook  and  divided ;  or  the  sharp  tenotome  can 
be  introduced  at  a  point  half  way  between  the  anterior  and  internal 
borders  of  the  tibia  and  passed  so  as  just  to  graze  the  inner  margin 
of  that  bone.  The  blunt  tenotome  is  then  introduced  through  the 
same  opening  and  thrust  flatwise  farther  under  the  tendon,  the  edge 
then  turned  outward  and  "  the  tibia  used  as  a  fulcrum  "  ( Jacobson) 
while  the  tendon  is  severed,  usually  that  of  the  flexor  longus  digit- 


FiG.  282.      Same    as    Fig.    280,    after  Fig.  283.    Same  as  Figs.  280  and  282, 

correction  of  varus  by  tenotomy  of  varus  corrected,  the  tendo-Achillis 

tibiales    and    plaster    bandages    ap-  still  maintaining  the  equinus. 
plied. 

orum  being  cut  with  it.  The  plantar  fascia  may  be  cut  at  any  point, 
or  at  several  points  that  seem  to  need  it,  at  the  bottom  of  the  con- 
cavity on  the  inner  border  of  the  foot.  The  tenotome  is  introduced 
on  the  inner  side  of  the  foot  and  passed  flatwise  between  the  skin 
and  fascia  (which  is  not  kept  tense  during  this  step)  until  its  point 
has  reached  the  outer  margin  of  the  fascia.  The  edge  of  the  blade 
is  then  turned  toward  the  fascia,  now  made  tense,  and  with  a  saw- 
ing motion  divides  it  until  it  yields.  If  there  be  present  a  marked 
degree  of  varus  it  is  better  to  correct  this  before  dividing  the  tendo- 
Achillis,  leaving  the  latter  to  hold  the  heel  firmly  while  the  surgeon 
straightens  the  pes  upon  the  talus.  (Figs.  282,  283.)  One  or  both 
tibiales  and  the  fascia  having,  if  necessary,  been  divided,  the  tenot- 
omy wounds  dressed  antiseptically,  and  the  deformity  of  the  foot  it- 
self corrected  and  over-corrected,  it  is  held  so  and  put  up  in  a  plaster 
bandage.  The  plaster  can  be  applied  next  the  skin,  but  it  is  better 
to  cover  the  skin  and  surgical  dressing  with  a  flannelette  roller  be- 
fore the  plaster.    The  plaster  leaves  the  toes  exposed  but  extends  up 


CLUBFOOT  AND  SOME  OTHER  DEFORMITIES 


731 


the  leg.  If  there  is  a  tendency  to  inversion  of  the  leg  and  foot,  or 
if  the  heel  is  very  small,  the  plaster  would  better  be  extended  above 
the  flexed  knee,  the  foot  being  held  in  over-correction  and  rotated 
outward  while  the  plaster  is  being  applied  and  until  it  hardens.  In 
a  few  weeks  the  case  is  one  of  simple  equinus,  and  can  be  corrected 
by  division  of  the  tendo-Achillis.  This  tendon  is  cut  subcutane- 
ously  ^  at  its  narrowest  part  a  half-inch  or  more  above  its  insertion, 
passing  the  tenotome  from  the  inner  side  between  the  posterior  tibial 
artery  and  the  tendon,  and 
cutting  toward  the  surface. 
The  equinus  is  corrected  and 
slightly  over-corrected  and 
the  member  put  up  in  plaster. 
Formerly  it  was  the  practice 
not  to  correct  the  deformity 
immediately  at  the  time  of 
the  tenotomy,  but  to  wait  a 
week  or  more,  and  then  make 
the  correction.  But  that  de- 
lay is  not  necessary  nor  use- 
ful. The  plaster  bandages 
will  need  renewing  once  in 
a  fortnight,  or  a  month  or 
more,  perhaps  until  the  in- 
fant is  ready  to  walk.  It 
may  then  be  allowed  to  walk 
with  the  foot  encased  in  plaster  or  a  retention  splint ;  or  if  pre- 
ferred, a  walking  shoe  may  be  used.  The  retention  splint  or  shoe 
is  merely  a  metal  sole  and  heelpiece  with  straps  to  hold  the  foot 
upon  it,  and  fitted  with  a  rigid  upright  at  each  side  of  the  ankle 
running  to  a  band  encircling  the  leg.  (See  Fig.  285.)  It  is  placed 
upon  the  foot  and  an  ordinary  shoe  put  on  over  it.  The  walking 
shoe  is  made  with  the  uprights  jointed  at  the  ankle,  placed  inside 
of  the  shoe,  not  fastened  to  it,  and  sometimes  has  a  toe-lift  running 
from  the  outer  side  of  the  foot  to  the  encircling  band  upon  the  leg. 
The  joint  at  the  ankle  is  best  made  so  that  it  can  be  flexed  but  can- 
not be  extended  beyond  a  right  angle  and  needs  no  toe-lift.  Such 
apparatus  is  not  expected  to  exert  corrective  force.  It  merely  re- 
tains, without  pressure,  the  corrected  position  and  prevents  relapse. 
It  should  be  worn  until  there  is  no  possible  tendency  toward  re- 
lapse. If  there  is  any  inclination  toward  "  pigeon-toe  "  or  inward 
rotation  of  foot  and  leg,  the  uprights  should  be  extended  above  the 
knee  (and  better  even  to  a  pelvic  band)  and  given  an  outward  turn 
to  correct  that  deformity.      (See  Fig.  286.) 

1  A  better  procedure  is  tendon-lengthening. 


Fig.  284.  Same  as  Fig.  283,  after 
tenotomy  of  tendo-Achillis  and  use 
of  plaster  bandages. 


Il-^- 


SURGICAL  DISEASES  OF  CHILDREN 


Very  few  cases  of  equino-varus  in  children  require  any  more 
severe  treatment  than  that  described.  In  older  children,  who  have 
been  neglected  and  in  relapsed  cases  other  procedures  must  be  re- 
sorted to. 


J  Fig.  285.    Retention  brace  for  clubfoot. 

Treatment  of  Neglected  and  Relapsed  Eqidno-Vanis. — Cases 
of  neglected  and  relapsed  clubfoot  usually  require  more  than  or- 
dinary preparation,  during  several  days 
or  a  week  before  operation.  Corns  and 
callosities  should  be  removed  by  poul- 
tices of  soap  or  flaxseed  and  soaking  in 
soda  solutions.  Then  cosmoline  at  night 
and  daily  scrubbing  with  mercuric  solu- 
tions and  alcohol  will  render  the  skin 
pliable  and  comparatively  aseptic.  On 
the  evening  before  and  the  morning  of 
the  operation  the  usual  antiseptic  prep- 
arations are  made. 

These  cases  may  be  treated  by 
stretchings  and  modelings,  under  anesthe- 
sia, with  or  without  tenotomies  or  fascio- 
tomies.  Manual  strength  alone  is  usu- 
ally not  sufficient.  But  much  force  may 
be  accurately  applied  by  the  hands  of  the 
surgeon  in  modeling  a  foot  and  stretch- 
ing short  structures  across  a  wedge- 
shaped  fulcrum.  (See  Fig.  287.)  A 
clubfoot  wrench  or  similar  apparatus 
adds  immensely  to  the  power  of  the  hand,  though  it  does  not  in- 
crease but  rather  decreases  the  accuracy  with  which  the  force  is  ap- 


FiG.  286.    Walking  shoes 

FOR       DOUBLE       CLUBFOOT, 

when  there  is  also  in- 
ward rotation  or  pigeon 
toe. 


CLUBFOOT  AND  SOME  OTHER  DEFORMITIES 


733 


plied.     (See  Fig.  288.)     After  the  reshaping  of  the  foot  it  is  put  up 
in  plaster  of  Paris. 

Phelps^  operation. — It  is  sometimes  advisable  in  neglected  or 


Fig.  287.    Author's   metallic  fulcrum.     An  im- 
provement on  the  Konig  block. 

relapsed  cases  in  older  children  or  adolescents,  where  the  bones, 
however,  are  not  too  severely  deformed,  to  make  an  open  section  of 


Fig.  2 


Clubfoot  wrenches. 


all  contracted  structures  on  the  concave  side  of  the  foot.  The  Es- 
march  bandage  is  used.  The  incision  is  just  in  front  of  and 
beneath  the  internal  malleolus  and  extends  obliquely  forward  and 


734  SURGICAL  DISEASES  OF  CHILDREN 

across  one-fourth  or  one-half  the  sole  and  divides  all  resisting 
soft  parts  on  the  inner  and  lower  border  of  the  foot.  Skin  and 
fascia,  tendons,  muscles,  ligaments,  are  divided  sufficiently  to  allow 
correction  of  the  deformity  to  be  made  with  powerful  use  of  the 
wrench  or  other  force.  Care  should  be  taken  that  the  astragalus 
and  calcaneum  do  not  remain  in  faulty  position  with  relation  to 
tibia  and  fibula.  The  posterior  ligament  and  the  tendo-Achillis 
may  require  section.  Rubber  tissue  or  cyanide  gauze  is  placed 
next  the  incision,  an  antiseptic  dressing  firmly  applied,  the  Es- 
march  removed,  the  foot  and  leg  put  up  in  plaster  of  Paris  and 
kept  elevated  for  twenty-four  hours.  The  first  dressing  remains 
on  a  month.  Usually  the  wound  is  healed  by  this  time.  When 
healing  is  complete  use  retention  splint  or  walking  shoe.  The 
Phelps  operation  has  the  advantage  of  lengthening  the  foot,  while 
cuneiform  tarsectomy  shortens  it. 

Cuneiform  Tarsectomy. — This  operation  may  be  used  when 
the  bones  are  too  seriously  misshapen  for  the  Phelps  operation.  It 
has  the  disadvantage  of  shortening  the  foot.  It  consists  in  making 
an  incision  longitudinally  over  the  most  prominent  part  of  the  con- 
vexity of  the  foot,  reflecting  all  the  soft  parts  without  injury  to 
the  tendons  and  excising  a  wedge  of  bone.  Care  should  be  taken 
to  have  the  wedge  of  sufficient  size  to  permit  correction  of  the  de- 
formity. 

Cook's  operation. — It  is  claimed  for  this  operation  that  it  op- 
poses flat  clean-cut  surfaces  of  bone  with  no  bruising  or  mangling 
of  surrounding  tissues  and  no  cavity  to  fill  up ;  and  that  if  the 
wedge  of  bone  is  sufficiently  large  and  the  angles  of  the  wedge  are 
correct,  there  is  no  tendency  to  relapse,  as  every  step  the  patient 
takes  tends  to  maintain  the  foot  in  its  new  position.  It  is 
performed  as  follows:  First,  if  necessary  subcutaneously  di- 
vide the  fascia  on  the  inner  side  of  the  foot  and  also  the  heel- 
cord,  and  then  bring  the  foot  into  as  good  position  as  possible, 
using  nothing  but  the  hands  and  being  careful  not  to  bruise  the 
tissues.  Next  make  an  incision  through  the  skin  and  superficial 
fascia,  just  in  front  of  the  external  malleolus.  Viewed  from 
the  outer  side  this  incision  should  be  perpendicular  from  just 
above  the  bend  of  the  ankle  to  the  sole. 

Next  with  an  osteotome  remove  a  large  wedge  of  bone,  mak- 
ing the  first  incision  far  back,  just  in  front  of  the  fibula  and  going 
completely  across  the  bones.  Be  sure  to  get  the  wedge  large 
enough.  The  foot  can  now  be  brought,  without  force,  into  ex- 
cellent position ;  and  by  giving  the  anterior  part  of  the  foot  a  quar- 
ter turn,  its  outer  border  should  be  elevated.  Before  closing  the 
wound,  see  that  the  cut  surface  of  the  anterior  part  of  the  foot 


CLUBFOOT  AND  SOME  OTHER  DEFORMITIES  735 

does  not  project  so  high  as  to  interfere  with  extreme  flexion  of 
the  ankle.  No  sutures,  excepting  skin  sutures  are  required.  Gauze 
dressing  and  then  plaster  are  applied.  Dr.  Cook  uses  a  slight  re- 
tention splint  in  preference  to  plaster.     Children  may  walk  after 


Fig,  289.    Two  pairs  of  feet.    Each  pair  has  one  foot  paralyzed  and  the 

OTHER  SOMEWHAT  FLATTENED  FROM  EXTRA  WEIGHT-BEARING.       One  paralyzed 

foot  has  a  degree  of  cavus  ;  and  the  other  a  degree  of  valgus,  a  flail  joint 
at  ankle,  and  contracted  toes.     To  this  foot  belongs  the  brace  shown. 

two  weeks.  Dressing  is  worn  six  or  eight  weeks  and  then  an  or- 
dinary shoe. 

Treatment  of  Varus. — This  has  been  sufficiently  discussed  in 
the  treatment  of  equino-varus. 

Treatment  of  Valgus. — The  congenital  form  generally  yields 
to  repeated  manipulations,  with  stretchings  of  contracted  tissues, 
followed  by  plaster.  In  neglected  or  relapsed  forms  tenotomy  of 
the  contracted  tendons  or  tarsectomy  may  be  required.  In  the 
rachitic  form  the  treatment  consists  in  massage  and  corrective 
movements,  alternating  exercise  and  rest  periods,  a  shoe  with  sole 
thicker  upon  the  inner  side  to  throw  the  weight  upon  the  outer 
border  of  the  foot  and  a  felt  pad  or  metal  support  under  the  arch. 
(See  also  Sections  on  Pes- Planus  and  on  Weak  Ankles.) 

In  paralytic  valgus,  a  very  common  result  of  poliomyelitis, 
transplantation  of  some  of  the  contracted  tendons  to  the  inner  side 
of  the  foot  may  be  useful.  And  the  possibilities  of  nerve  trans- 
ference should  be  considered.  A  proper  shoe  and  arch  support, 
perhaps  also  an  ankle  brace  may  solve  the  problem.  In  extreme 
paralysis  or  flail-foot,  arthrodesis  at  the  ankle  joint,  or  better  still, 


736  SURGICAL  DISEASES  OF  CHILDREN 

astragalectomy,  often  render  the  foot  useful.  Astragalectomy 
gives  a  considerable  degree  of  stability  with  some  motion,  un- 
avoidably  with   some   shortening. 

The  treatment  of  static  valgus,  an  exaggerated  form  or  de- 
gree of  flat-foot  with  eversion,  is  sufficiently  described  under  the 
caption  of  planus.  Traumatic  valgus  is  extremely  rare  in  children. 
It  comes  as  a  result  of  crushing  injury  to  the  foot  with  union  in 
deformity,  or  to  fracture  of  tibia  and  fibula  near  the  ankle  with 
angular  union  leading  to  eversion  of  the  whole  foot.  Treatment 
consists  in  refracture  or  osteotomy,  with  correction  or  rather  over- 
correction, fixation  until  firm  union  takes  place  and  then  the  use  of 
a  shoe  or  brace,  massage  and  exercises  until  complete  restoration 
to  function. 

Treatment  of  Equinus. — This  has  been  sufficiently  described 
with  equino-varus. 

Ti'eatment  of  Calcaneus. — Congenital  calcaneus  seldom  requires 
tenotomy.  If  manipulations  do  not  suffice  a  brace  should  be  worn 
with  its  ankle  joint  so  constructed  as  to  allow  extension  but  not 
flexion  beyond  a  right-angle.  Acquired  calcaneus  is  generally  ac- 
companied by  cavus  or  valgus.  Manipulation,  stretchings,  gypsum 
and  braces  may  be  considered  but  are  very  disappointing.  Whit- 
man operates  by  making  a  long  external  incision  behind  and  above 
the  external  malleolus,  going  below  its  extremity  and  terminating 
at  the  end  of  the  astragalus.  The  peronei  tendons  are  divided  far 
forward  and  reflected,  the  joint  is  opened  and  the  foot  displaced  in- 
ward. The  astragalus  is  eneucleated.  Sections  of  bone  are  re- 
moved from  the  outer  surface  of  the  oscalcis  and  cuboid.  On  the 
inner  side  the  sustentaculum  tali  is  removed  and  the  calcaneo-navi- 
cular  ligament  separated.  The  cartilage  is  re-moved  frorn  both 
malleoli.  The  foot  is  then  displaced  backward  as  far  as  possible, 
bringing  the  external  malleolus  over  the  calcaneo-cuboid  juncture. 
The  internal  malleolus  is  pushed  into  the  depression  behind  the 
scaphoid.  If  the  peronei  are  active  they  are  used  to  reenforce  the 
tendo-Achillis.  The  foot  is  put  up  in  plaster  in  the  equinus  posi- 
tion. 

Jones  advises  ^  an  operation  in  two  varieties  and  done  in  two 
stages  as  follows:  (a)  Calcaneo-cavus  where  calf-paralysis  is 
complete.  Stage  I.  The  plantar  fascia  is  divided  if  contracted 
and  the  foot  straightened  as  much  as  possible  with  hands  or 
wrench.  An  incision  down  to  the  bone  is  made  on  the  inner  side 
of  the  foot,  with  its  center  opposite  the  angle  of  the  cavus.  With 
periosteum  elevator  the  soft  parts  are  separated  from  the  tarsus 

1  Jones:  Amer.  Jour.  Orth.  Surg.,  Apr.,  1908;  Liverpool  Medico-Chirurgi- 
cal  Journal,  Jan.,  1909. 


CLUBFOOT  AND  SOME  OTHER  DEFORMITIES  737 

both  above  and  below,  from  inner  to  outer  side.  A  V-shaped  sec- 
tion extending  across  the  tarsus  is  removed.  If  valgoid  deformity- 
is  also  present,  the  section  should  be  wider  upon  the  inner  than  the 
outer  side.  If  necessary  the  foot  may  be  opened  on  the  outer  as 
well  as  on  the  inner  side  in  removing  the  wedge.  Sutures  are 
placed  and  the  deformity  of  the  foot  is  then  obliterated  by  extend- 
ing it.  The  foot  is  bandaged  to  the  tibia  in  a  position  of  ex- 
aggerated calcaneus.  Stage  II.  Four  weeks  after  the  first  stage. 
A  longitudinal  incision  is  made  back  of  the  heel  with  its  center 
opposite  the  ankle  joint.  The  joint  is  opened  and  from  the  astra- 
galus a  wedge  is  removed  sufficiently  large  to  be  accurately  ob- 
literated when  the  foot  is  brought  to  a  right  angle.  The  cartilage 
is  removed  from  the  tibia  and  fibula.  The  wound  is  sutured  and 
the  foot  put  up  in  fixed  dressings,  (b)  Calcaneo-cavus  where 
some  power  remains  in  the  calf  muscles.  Stage  I  is  the  same  as  in' 
(a).  Stage  II.  Shortening  of  the  capsule  and  of  the  tendo-Achillis 
are  performed. 

Treatment  of  Cavus. — Slight  cases  in  young  children  with  a 
flexible  foot  may  yield  to  the  force  of  the  surgeon's  hands,  fol- 
lowed by  the  use  of  a  metal  sole  with  a  broad  strap  over  the  arch. 
But  a  footwrench  or  even  an  osteoclast  may  be  required  to  lower 
the  arch,  even  after  division  of  the  plantar  fascia  and  contracted  ten- 
dons. When  complicated  by  equinus  lengthening  of  the  Achillis 
tendon  will  be  required,  but  this  should  not  be  done  until  after  the 
work  upon  the  foot  itself  has  been  completed. 

Treatment  of  Planus. — Pes  planus,  broken  arch  or  weak  foot 
is  so  common  as  to  deserve  considerable  attention.  It  must  be 
treated  according  to  its  cause  and  its  degree.  Infants  about  learn- 
ing to  walk  are  often  brought  by  anxious  mothers  who  fear  flat- 
foot  because  no  arch  is  apparent.  This  condition  is  scarcely  ab- 
normal at  this  stage  of  development,  and  if  the  babe  is  healthy,  dis- 
appears with  farther  development  and  education  of  the  muscles. 
But  search  should  be  made  for  evidences  of  malnutrition,  rickets, 
actual  malformation  of  bones,  paralysis  or  contractions. 

That  class  of  weakened  tarsal  arches  common  in  older  child- 
hood and  adolescence  and  due  usually  to  a  combination  of  weak 
musculature,  ill-shaped  and  high-heeled  shoes  and  too  much  stand- 
ing, can  be  cured  only  by  attention  directed  to  the  cause  or  all  the 
causes;  and  when  these  have  resulted  also  in  actual  elongation  of 
the  plantar  ligaments  and  the  high  heels  have  produced  contrac- 
tion of  the  gastrocnemeus  and  soleus,  or  when  in  addition  to  the 
causes  mentioned  there  is  also  knock-knee,  sabre-leg,  inbowed-leg 
or  partial  paralysis,  the  case  is  one  of  difficulty  and  involves  treat- 
ment  of   more   than  merely  the   feet.     Cases   which   have  become 


738  SURGICAL  DISEASES  OF  CHILDREN 

painful  or  tender  will  be  made  more  comfortable  by  rest,  hot  and 
cold  douching,  water  compresses,  and  hot-air  baking.  When  pain 
and  tenderness  are  not  present  or  have  been  relieved,  a  course  of 
muscular  improvement  should  be  pursued  persistently.  The  tibial 
muscles  especially  should  be  exercised  by  adducting  and  inverting 
the  foot,  and  the  toe  muscles  by  using  them  to  pick  up  marbles  from 
the  floor  and  similar  exercises.  Then  all  the  muscles  of  the  foot 
and  leg  go  into  training  with  circumduction  and  this  with  resistance 
applied  by  the  hand,  tiptoe  and  pigeon-toe  and  varic  walking,  bare- 
footed or  in  stockings  only.  Corrective  walking  should  be  prac- 
ticed by  treading  upon  the  outer  borders  of  the  feet,  with  toes 
straight  forward  or  inward,  never  outward,  and  taking  as  long  steps 
as  the  contracted  calf  muscles  will  permit.  Exercises  should  never 
be  carried  to  over-fatigue  and  should  be  followed  by  the  hot  and 
cold  douche,  massage  and  rest.  For  those  who  are  obliged  to  be 
much  upon  their  feet,  the  muscles  should  also  be  temporarily  as- 
sisted by  strapping  systematically  in  layers  with  adhesive  plaster  as 
one  does  for  sprain  of  the  ankle  (Gibney's  method),  carrying  the 
straps  from  the  outer  side  of  the  leg  under  the  heel,  under  the  arch, 
and  up  the  inner  side  of  the  leg. 

Proper  shoes  are  essential.  The  shoe  should  have  a  low 
broad  heel.  On  the  inner  side  the  heel  may  extend  forward  under 
the  arch.  It  should  be  roomy  at  the  toes.  The  inner  border  should 
be  straight  or  even  concave  throughout.  It  is  useful  to  have  the 
sole  and  heel  of  the  shoe  thicker  on  the  inner  than  on  the  outer 
border  by  applying  leather  of  one-sixteenth  to  one-fourth  inch 
thickness. 

Various  so-called  arch-supports  or  sole  plates  have  been  de- 
vised. An  insole  of  leather  or  of  felt  and  leather  may  be  arched 
upward  on  its  inner  side  so  as  to  support  the  arch  in  a  more  natural 
position.  Such  an  insole  and  shoe  raised  on  the  inner  half  of  the 
sole  are  often  all  that  is  necessary  in  infants  and  young  children. 
For  older  ones  there  are  sole  plates  of  many  materials  and  varieties 
that  need  not  be  described  in  detail.  Those  for  sale  ready  made 
seldom  fit  the  individual  case.  Some  are  arched  upon  the  outer 
side,  raising  that  border  of  the  foot  from  the  ground,  which  is  al- 
ways an  error;  and  some  attempt  too  much  correction  of  the  trans- 
verse arch.  The  object  of  the  plate  is  not  merely  to  raise  the 
longitudinal  arch  from  the  floor,  but  to  shift  the  weight  to  the  outer 
side  of  the  foot.  The  inner  margin  of  the  plate  should  curve  up 
high  enough  to  support  the  scaphoid  and  astragalus.  Among  the 
many  kinds  of  modelled  plates  those  of  German  silver  have  served 
my  purpose  best.  This  metal  in  the  rolled  plate,  gauge  i8,  can  be 
shaped   with  a  hammer  by  a  skilled  mechanic ;  and  when  nickel- 


CLUBFOOT  AND  SOME  OTHER  DEFORMITIES 


739 


plated  or  when  it  contains  eighteen  per  cent,  nickel  alloy,  simply 
burnished,  it  makes  a  strong,  light,  smooth  and  durable  arch  sup- 
port that  can  be  modified  in  shape  to  suit  the  changing  arch.  The 
plate  can  be  modelled  from  a  diagram  of  the  sole  drawn  while  the 
patient  stands  upon  a  sheet  of  paper.  The  pencil  traces  the  out- 
line closely  around  the  edge  of  the  sole  and  then,  the  arch  being 
raised  from  the  paper,  the  pencil  is  passed  beneath  the  inner  bor- 
der of  the  foot  and  the  outline  of  the  arch  is  traced.  Or  a  plaster 
cast  of  the  foot  may  be  made  by  placing  the  foot  smeared  with  vase- 
line, without  weight-bearing,  in  a  shallow  box  of  plaster  of  Paris 
and  water  mixed  to  the  consistency  of  thick  cream.  Care  should 
be  taken  to  have  the  plaster  cover  the  foot  upon  the  inner  side  above 
the  level  of  the  scaphoid  and  astragalus.  When  the  plaster  has 
firmly  set  the  foot  is  removed,  the  mold  smeared  inside  with  vaseline 
and  filled  with  creamy  plaster  to  make  a  cast.  This  cast  may  then 
be  shaved  to  the  degree  of  correction  desired  and  serves  for  a  model 
for  the  mechanic.  Or  the  foot  may  be  encased  in  a  plaster  band- 
age which,  being  cut  off,  serves  for  a  mold  to  make  the  cast.  In 
working  with  young  and  fidgety  children  or  when  in  haste  I  have 
found  it  convenient  to  use  modeling  wax  or  plasticine  or  sometimes 
the  doughy  mixture  known  as  wallpaper  cleaner  to  take  the  mold  of 
the  foot.  Too  much  correction  should  not  be  attempted  with  one 
plate  lest  tenderness  result.  It  is  better  if  necessary,  to  make  new 
plates  or  remodel  them  at  inter- 
vals, as  the  foot  improves. 

Compound  forms. — The 
compound  forms  occurring  occa- 
sionally are  treated  by  an  adapta- 
tion of  the  same  principles  as 
have  already  been  discussed. 

WEAK  ANKLES 

Sometimes  associated  with 
talipes  planus  or  valgus,  and 
sometimes  occurring  alone,  are 
weak  ankles.  (Fig.  290.)  The 
parts  are  neither  malformed, 
paralyzed  nor  contracted,  but  the 
muscles  are  simply  too  weak  to 
maintain  the  proper  position  of 
the  ankle  joint  with  the  patient 
standing.  They  relax  and  sag  to 
the  inside. 

Treatment. — The  treatment  consists  in  properly  managed  rest 
and  exercise,   massage,  baths,   sometimes   electricity,   general   tonic 


Fig.  290.  Weak  ankles  and  tal- 
ipes VALGUS.  Girl  has  also  lateral 
curvature  of  spine.  Eight  years 
old. 


740 


SURGICAL  DISEASES  OF  CHILDREN 


and  hygienic  measures  as  described  for  pes  planus  and  for  those  who 
are  obHged  to  be  much  upon  their  feet,  some  form  of  support  for 
the  muscles  that  does  not  interfere  with  their  action,  until  they  have 
developed  adequate  strength.  A  good  way  is  to  apply  adhesive 
straps  as  in  Gibney's  method  of  treating  sprains  of  the  ankle  but 
carrying  the  strapping  well  up  the  leg.  For  infants  just  learning  to 
walk  the  only  brace  necessary  is  the  high  soleleather  counter  made 

for  the  purpose  and  worn  in- 
side the  ordinary  shoe.  For 
older  children,  in  severe 
cases,  a  simple  brace  with  an 
upright  fastened  to  the  shoe 
and  extending  part  way  up 
the  leg  to  an  encircling  leg- 
band  and  a  pad  opposite  the 
inner  side  of  the  joint.  The 
joint  for  the  ankle  should 
allow  vertical  but  not  lateral 
movement.     (Fig.  140.) 

CLUBHAND 

Clubhand  is  a  rare  de- 
formity. It  is  usually  asso- 
ciated with  or  produced  by 
absence  or  faulty  develop- 
ment of  the  lower  end  of  the 
radius  or  ulna,  the  hand 
being  distorted  with  relation 
to  the  forearm.  The  hand 
may  be  drawn  to  or  beyond 
the  right  angle  on  the  radial 
or  the  ulnar  side  or  in  flexion 
or  extension. 

Treatment. — This  de- 
formity is  not  very  amen- 
able to  treatment.  If  begun 
quite  early,  and  used  per- 
sistently, treatment  by 
splints  and  various  forms  of 
braces,  together  with  mas- 
sage and  systematic  exer- 
cises, may  do  much  to  ameliorate  the  condition  and  prevent  its 
becoming  still  more  distorted.  Cases  have  been  reported  treated 
by  transplantation  of  bone  into  the  forearm,  also  by  exsection  of  a 
portion  of  the  bone  that  exceeds  the  other  in  length  so  as  to  bring 


Fig.  291.  Supernumerary  fingers.  A 
rudimentary  sixth  digit  attached  to  the 
outer  border  of  each  little  finger. 


CLUBFOOT  AND  SOME  OTHER  DEFORMITIES 


741 


the  articulating  ends  on  a  level,  and  by  other  atypical  operations. 
But  there  is  no  systematic  method  of  treatment  comparable  to  that 
for  clubfoot. 

SUPERNUMERARY  ARMS  OR  LEGS,  HANDS  OR  FEET 

Reduplication  of  a  large  extremity,  or  of  a  large  or  complex 
portion  of  an  extremity,  is  a  very  rare  deformity,  and  its  considera- 


^  ~''^ 

■ 

i 

r.  vvR 

y  /■' 

L--  ' 

■^-^^  ^f  Jfeflirf-'-'iMiiii 

ntr    ^ 

^^  ^m 

hhh 

jHuj^^ 

IH 

Fig.  292.     Supernumerary  fingers.     A  sixth   digit  attached  to  the  ulnar 
border  of  each  hand. 


Fig.  293.     Supernumerary  toe. 

tion  can  be  given  little  space.  The  etiology  of  this  curious  mal- 
formation by  excess  of  development,  which  is  evidently  inherent  in 
the  embryo,  has  been  referred  to  in  the  Section  on  the  general  sub- 
ject of  the  Malformations,  and  on  Teratomata. 

Treatment. — As  a  rule  the  extra  member  is  neither  useful  nor 
ornamental  and  should  be  removed  when  this  can  be  done  with 
safety. 


742  SURGICAL  DISEASES  OF  CHILDREN 

SUPERNUMERARY  DIGITS  (POLYDACTYLISM) 

The  smaller  and  simpler  structures  are  those  more  frequently 
found  in  excessive  number,  Polydactylism  may  affect  either  fingers 
or  toes,  or  both  in  the  same  individual ;  may  be  symmetrical  on  the 
two  sides,  or  occur  on  only  one  side,  or  each  hand  or  foot  may  show 
from  one  to  three  or  four  supernumerary  digits. 

The  supernumerary  member  or  members  may  be  rudimentary 
like  a  mere  protuberance,  or  be  more  fully  formed  even  to  complete 
development,  and  be  merely  appendages  or  capable  of  partial  or 
perfect  motion.  Polydactylism  is  frequently  but  not  always  hered- 
itary. 

Annandale  classified  supernumerary  digits  into  four  varieties 
according  to  their  degree  of  development  and  mode  of  connection 
with  normal  anatomical  parts.  Figs.  292,  293,  and  294  represent  the 
first  and  second  varieties  of  Annandale's  classification. 

Treatment. — In  dealing  with  the  hand,  especially  if  the  patient 
be  a  female  child,  much  care  should  be  taken  to  preserve  symmetry 
and  a  smooth  outline  and  to  avoid  scarring.  As  a  rule  the  earlier 
the  deformity  can  be  dealt  with  the  better  and  in  all  cases  strict 
antiseptic  principles  should  be  observed.  Supernumerary  digits 
attached  loosely  by  a  pedicle  should  be  snipped  off. 

Extra  digits  of  the  second  class,  having  joint  attachment  but 
no  voluntary  motion,  should  also  be  removed  with  antiseptic  pre- 
cautions. In  case  a  supernumerary  finger  and  the  normal  one  are 
very  closely  connected  in  a  common  capsule  it  may  be  better  to  di- 
vide the  proximal  phalanx  of  the  supernumerary  digit  outside  the 
articulation. 

In  the  third  variety,  in  which  a  perfect  digit  articulates  with  a 
metacarpal  or  metatarsal  of  its  own,  it  is  usually  advised  not  to  in- 
terfere. In  the  fourth  variety,  in  which  the  supernumerary  is 
united  throughout  with  another  digit,  it  is  seldom  advisable  to  at- 
tempt removal. 

INTRA-UTERINE  AMPUTATIONS  AND   CONSTRICTIONS  AND 
SUPPRESSION  OF  INTERMEDIATE  PARTS,  AB- 
SENCE OF  PARTS 

Cases  occur  with  great  rarity  in  which  amputation  of  more  or 
less  of  an  extremity  takes  place  in  utero  by  the  constricting  force 
of  bands  of  lymph  stretched  from  one  part  of  the  uterus  to  another, 
or  from  one  part  of  the  fetus  to  another  and  the  amputated  part 
is  found  lying  loose  in  utero.  It  is  less  uncommon  to  find  the  am- 
putation stump  without  any  trace  of  the  dissevered  member,  which 
has  become  disintegrated,  the  amputation  having  taken  place  very 
early  in  fetal  life.     In  other  instances  grooves  or  fissures  are  found 


CLUBFOOT  AND  SOME  OTHER  DEFORMITIES 


743 


Fig.  294.  Malformation  left  hand. 
Index,  middle  and  ring  fingers  rudi- 
mentary. Thumb  and  fourth  finger 
useful.     Referred  by  Dr.  R.  Bailey. 


of  greater  or  less  depth  surrounding-  a  limb  as  though  the  constrict- 
ing band  had  begun  but  failed  to  complete  the  amputation. 

Another  group  of  cases 
has  an  intermediate  segment 
of  a  limb  suppressed,  and  the 
distal  parts  or  rudiments  of  it 
attached  to  what  remains  of 
the  limb.  For  instance,  the 
forearm  may  be  absent,  and 
fingers  project  from  the  lower 
end  of  the  upper  arm.  Again, 
distal  parts  of  an  extremity, 
as  fingers  or  toes,  hand  or 
foot,  may  be  absent  or  rudi- 
mentary. (Fig.  294.)  In 
some  of  these  cases  of  sup- 
pression and  of  absence  of 
parts  it  may  be  impossible  to  determine  whether  the  condition  was 
caused  by  pressure,  amputation,  or  originated  in  a  fault  in  the 
embryo  itself. 

Treatment. — Most  cases  under  this  heading  admit  of  no  treat- 
ment. 

WEBBED  FINGERS  OR  TOES  (SYNDACTYLISM) 

This  is  a  rather  common  deformity.     It  may  be  a  family  mark 
occurring  occasionally  through  hereditary   influence  in   successive 

generations.  Or  it  may  occur 
in  single  instances.  Some 
cases  are  apparently  caused  by 
the  parts  being  enveloped  in 
lymph  bands,  and  may  show 
amputation  of  a  portion  of  the 
digits  and  webbing  of  the 
stumps.  There  are  varying  de- 
grees of  the  deformity.  The 
normal  web  may  merely  be  ex- 
tended too  far  forward  or  may 
unite  two  or  three  of  the  pha- 
langes. More  rarely  the  web 
may  be  present  between  the 
distal  and  not  the  proximal 
phalanges. 

Again,  instead  of  a  merely 
cutaneous  union,  the  deeper  tissues,  even  the  metacarpal  or  metatarsal 
and  phalangeal  bones,  may  be  fused  together.     The  malformation 


Fig.  295. 


Abnormal  alignment  of 

THE  TOES. 


744 


SURGICAL  DISEASES  OF  CHILDREN 


is  apt  to  be  symmetrical  and  may  involve  either  hands  or  feet  or 
both.  It  is  not  uncommonly  associated  with  some  other  deformity. 
Treatment. — Webbing  of  the  toes  really  needs  no  treatment. 
If  adjacent  fingers  are  united  by  union  of  the  bones  or  joints  they 
should  not  be  interfered  with.  If  they  are  united  only  by  skin  and 
fibrous  tissues  they  should  be  separated.  Simple  division  by  cutting 
effects  little,  since  the  wound  granulates  at  the  angle  and  the  parts 
gradually  reunite  more  or  less.  This  has  sometimes  been  obviated 
by  perforating  the  web  and  keeping  a  lead  or  silver  wire  or  stylet 
in  the  opening  until  it  healed  and  then  dividing  the  remainder  of 
the  web,  and  by  other  similar  methods.  Also  by  dividing  the  web 
and  then  turning  a  triangular  flap  of  skin  and  subcutaneous  tissue 
so  as  to  cover  the  angle  between  the  fingers,  and  prevent  their 
reunion  (Norton).  Finally  there  is  the  familiar  method  of  Didot 
figured  in  all  works  on  operative  surgery.  Two  skin  flaps  are  cut. 
One  is  raised  from  the  dorsal  aspect  of  one  finger  and  the  web, 
and  the  other  from  the  palmar  aspect  of  the  other  finger  and  the 
web.  The  flaps  being  raised,  the  remainder  of  the  union  is  cut 
through,  and  each  flap  is  wrapped  around  the  finger  to  which  it  re- 
mains attached.  Plastic  methods  should  not  be  undertaken  when 
the  parts  are  too  small  and  the  tissues  too  delicate  for  convenient 
work,  but  after  the  infant  or  child  is  older. 

IRREGULAR  ALIGNMENT  OF  DIGITS 

Deformity  may  occur  in  the  form  of  irregularity  in  the  align- 
ment of  the  phalanges  and  their  metacarpals  or  metatarsals.  (See 
Fig.  295.)  This  may  be  congenital  or  may  result  from  shoe- 
pressure.  Early  and  persistent  treatment  by  manipulation  and  ad- 
hesive plaster  and  only  broad  toed  stockings  and  shoes  may  suffice. 
But  if  ulcerations,  callosities  or  contractures  are  troublesome  it  is 
better  to  amputate  the  toe. 

PIGEON-TOE 

This  deformity,  in  its  most  aggravated  form,  has  been  described 
under  talipes  varus.  But  there  are  numerous  cases  of  toeing-in  of 
less  degree  which  demand  attention  from  the  children's  surgeon. 
The  incurvation  may  involve  no  more  than  the  great-toe,  or  it  may 
be  a  bending  of  the  pes  upon  the  talus,  or  an  inward  twist  of 
tibia  and  fibula,  or  an  in-knee,  or  inward  rotation  of  the  femur. 
Treatment  consists  in  persistently  repeated  forcible  untwisting  of 
the  affected  structures.  Voluntary  corrective  exercises,  under  in- 
struction, with  or  without  gymnastic  machinery,  are  very  effective. 
But  often  these  means  must  be  supplemented  by  apparatus  to  be 
worn.  In  babies  a  rubber  tape  attached  to  the  inner  side  of  the 
shoe,  carried  spirally  around  the  leg  and  thigh  and  fastened  out- 


CLUBFOOT  AND  SOME  OTHER  DEFORMITIES  745 

side,  at  the  hip,  sometimes  helps  in  mild  cases.  I  have  often  im- 
provised a  form  of  brace  made  of  brass  spring  wire  which  passes 
back  of  the  pelvis,  makes  a  spiral  turn  opposite  the  hip-joints, 
descends  to  the  knees  where  it  makes  another  spiral  turn  and 
descending  to  the  feet,  is  fastened  to  the  shoes  giving  them  an  out- 
ward turn.  Worn  outside  of  the  underclothing  or  diaper  this 
simple  device  is  not  uncomfortable.  It  can  be  used  in  conjunction 
with  plaster  casts  on  the  feet  in  talipes  varus.  Or  in  more  marked 
cases  a  regularly  constructed  brace  as  used  for  equinus-varus  (Fig. 
286)  can  be  used.  Or  the  uprights  extending  from  knee  to  pelvic 
band  in  such  a  brace  may  be  substituted  by  spiral  springs,  as  in 
Doyle's  brace  for  clubfoot  and  pigeon-toe. 


APPENDIX. 

(i)  Anesthetics,  (p.  41.)  As  a  local  anesthetic  the  hydrochloride  of 
quinine  and  urea  has  advantages  over  cocaine  and  others  in  being 
absolutely  free  from  toxic  effect  and  in  maintaining  anesthesia 
from  a  few  hours  to  several  days.  It  is  used  commonly  in  i  per 
cent.,  sterilized  solution,  and  is  rather  slovi^  in  taking  effect,  re- 
quiring from  5  to  30  minutes.  It  produces  local  edema,  a  disad- 
vantage in  some  operations,  but  of  no  moment  in  others. 

(2)  Hemorrhage,     (p.  45.)     The  pathological  conditions  favoring  hem- 

orrhage, such  as  hemorrhagic  diseases  of  the  new-born,  are  not 
here  under  discussion.  They  are  well  considered  in  the  standard 
works  on  medical  pediatrics.  See,  also,  Graham:  Jour.  Exper. 
Med.,  April  i,  1912. 

(3)  Shock.    Acapnia    as    a    cause,     (p.    46.)     Henderson    (Am.    Jour. 

Phys.,  1908,  Vol.  21,  p.  126;  1909,  Vol.  23,  p.  345;  Vol.  24,  p.  66; 
1909-10,  Vol.  25,  p.  385)  considers  shock  due  to  a  diminished 
amount  of  carbon  dioxide  in  the  blood,  a  condition  termed  (by 
Mosso)  acapnia.  Carbon  dioxide  being  a  hormone  or  chemical 
regulator  of  respiration,  is  held  responsible  also  for  the  failure  of 
the  circulation  and  the  nervous  system  in  shock. 

(4)  Shock.     Transfusion,     (p.  51.)     Transfusion  is  the  best  treatment 

for  shock  following  hemorrhage.  Done  with  Brewer's  glass  tube 
it  is  very  simple.  The  tubes  of  different  sizes  are  boiled  in  liquid 
albolene.  Artery  of  donor  and  vein,  basilic,  femoral,  or  external 
jugular  (Vincent)  of  donee  are  exposed  and  dissected  up  for  an 
inch  or  more.  Each  vessel  is  lifted  and  tied  distally  and  en- 
circled proximally  by  a  narrow  tape,  lightly  controlled  by  hemo- 
stat.  Each  vessel  is  severed  between  ligature  and  tape  and  the 
open  end  of  the  vessel  beyond  the  tape  washed  out  with  normal 
salt  solution,  and  then  smeared  inside  and  out  with  albolene.  A 
tube  of  proper  size  for  both  vessels  is  selected  from  the  hot  albo- 
lene, and  shaken  to  free  its  lumen  of  superfluous  albolene.  An 
end  of  the  tube  is  tied  into  the  vein  and  the  other  end  into  the 
artery.  The  small  amount  of  air  within  the  tube  may  be  dis- 
regarded. The  blood  is  allowed  to  flow  through  the  tube,  the 
proper  amount  being  measured  by  the  state  of  both  patients 
as  to  pulse  and  general  condition,  and  by  testing  the  hemoglobin 
of  the  donee  at  intervals  of  a  few  minutes. 

(5)  After  Operation,     (p.  51.)     Graham  claims  rectal  injection  of  olive 

oil  after  anesthesia  quickly  raises  the  opsonic  power  of  the  blood, 

747 


748  APPENDIX 

which  is  lowered  by  anesthesia  {Jour.  Infect.  Dis.,  1910,  viii,  147; 
Jour.  Am.  Med.  Assn.,  March  26,  1910,  p.  1043).  If  so,  would  not 
hypodermatic  use  of  olive  oil  be  better  still? 

(6)  Acromegaly,     (p.    61.)     Acromegaly    is    now    attributed    to    hyper- 

plasia or  an  adenomatous  condition  (with  over  activity)  of  the 
hypophysis.  Diminished  functionation  of  the  anterior  lobe  pro- 
duces adiposity  and  sexual  infantilism  (Crowe,  Gushing,  Homan: 
Johns  Hopkins  Hosp.  Bull.,  May,  1910.  For  Surgery,  see,  also, 
Kanavel:  Jour.  Am.  Med.  Assn.,  Nov.  20,  1909;  Surg.,  Gynec.  and 
Ohst.,  April,  1910;  Eiselberg:  Ann.  Surg.,  July,  1910). 

(7)  Tumors.    Morphological  study,     (p.  64.)     Mallory  says  {Jour.  Am. 

Med.  Assn.,  Oct.  29,  1910)  ".  .  .  every  simple  tumor  is  due  to 
the  proliferation  of  one  of  the  type-cells  and  that  the  blood  vessel 
and  stroma  are  furnished  by  the  surrounding  and  included  tissues 
and  are  not  themselves  tumor  cells.  The  type-cells  out  of  which 
the  tumor  is  built  is  the  one  important  element  and  gives  the 
name  to  the  tumor."  In  the  morphologic  study  of  epithelial 
tumors  he  insists  on  more  thorough  investigation  of  the  embryo- 
logic  origin  of  each  kind  of  epithelial  cell,  of  the  histological  dif- 
ferentiation which  each  type  of  cell  undergoes,  and  that  groups 
of  epithelial  tumors  should  be  studied  together  to  determine  rela- 
tionship, not  separated  as  in  a  clinical  classification. 

(8)  Angioma.     Naevus    and    cutaneous    nerves,    and    naevus    coincident 

zvith  paralysis,  (p.  84.)  Baerensprung  sees  a  relationship  be- 
tween naevus  of  head  and  face  and  the  cutaneous  branches  of 
the  trifacial  nerve.  Gushing  suggests  as  a  cause,  prenatal  dis- 
ease of  the  Gasserian  ganglion,  and  also  that  when  children  with 
trigeminal  naevus  develop  spastic  paralysis,  the  latter  is  due  to 
hemorrhage  from  a  coincident  nevus  of  the  dura  mater.  {Jour. 
Anier.  Med.  Assn.,  July  21,  1906.)  See,  also,  a  study  of  naevi  by 
Fitzwilliams  {Brit.  Med.  Jour.,  Sept.  2,  1911),  and  "Inherited 
Hemorrhagic  Telangiectasis,"  W.  Ostler.  {Riforma  Medica,  Jan. 
16,  1911,  xvii,  No.  3.) 

(9)  Nevus.     Treatment,     (p.  85.)     There  are  other  methods  of  freez- 

ing nevi,  for  instance  that  with  the  solid  carbon  dioxid.  The 
solid  carbon  dioxid  is  easily  prepared  from  the  compressed  gas 
sold  in  iron  cylinders  by  purveyors  to  the  soda  fountains.  A 
somewhat  porous  tube  of  the  size  of  the  vent  of  the  cylinder,  is 
prepared  by  rolling  a  piece  of  chamois  skin  or  a  towel  tightly 
round  a  rod,  the  rod  being  then  withdrawn  and  the  lower  end  of 
the  porous  tube  tied  shut.  The  cylinder  is  placed,  vent  down- 
ward, at  an  angle  of  45  degrees,  the  porous  tube  held  over  the 
vent  and  the  gas  allowed  to  escape  into  the  porous  tube  wherein 
a  deposit  of  snow  appears.  This  is  taken  from  the  towel  or 
chamois,  and  shaken  into  a  brass  tube  to  make  a  snow  pencil 
of  the  size  desired.  The  snow  may  be  rammed  firmly  into  the 
tube  with  a  rod  and  then  pushed  out  of  the  tube  in  the  form  of 


APPENDIX  749 

a  pencil  which  will  last  from  one  to  two  hours,  gradually  dwin- 
dling. It  can  be  handled  with  gloves  or  in  lint,  cut  with  a  knife 
to  suitable  shape  and  used  on  the  growth  by  applying  it  with 
pressure  for  5  to  30  seconds,  which  is  sufficient  to  freeze  the 
tissues.  During  the  thawing  process  there  is  some  smarting 
which  is  allayed  by  warm  water  compresses  but  soon  subsides. 
An  antiseptic  dressing  is  applied.  The  effect  is  considered  to  be 
not  an  escharotic  destruction  of  tissue,  but  causes  a  flooding  of 
the  treated  area  with  leucocytes  during  the  circumscribed  in- 
flammatory reaction,  with  increased  phagocytosis.  Experience  is 
necessary  to  judge  the  proper  duration  of  the  application  and  the 
degree  of  pressure.  Excellent  abstracts  of  the  literature  of 
the  subject,  with  references,  may  be  found  in  International  Medi- 
cal Annual,  1910,  p.  550,  pp.  306,  577;  1912,  p.  486. 

(10)  Hemophilia.     Etiology,     (p.  99.)     More  recently  it  is   considered 

due  to  defective  coagulability  of  the  blood.  The  nature  of  the 
blood-defect  is  in  dispute.  Addis  (Quar.  Jour.  Med.,  Oct.,  1910) 
reaffirms  that  it  is  an  inherited  peculiarity  of  the  prothrombin,  its 
activation  into  thrombin  being  retarded.  Sahli  {Brit.  Med  Jour., 
Nov.  5,  1910)  claims  defective  coagulation  is  due  to  lack  of 
thrombokinase  and  that  in  hemophilia  there  is  a  cellular  anomaly 
not  only  of  the  corpuscles  of  the  blood  but  of  the  endothelial 
cells  of  the  vessels. 

(11)  Hemophilia.     Treatment     by     blood    or    blood    serum,     (p.     99.) 

Transfusion  of  human  blood  may  control  the  hemorrhage  for  the 
time  being;  it  does  not  cure  the  tendency.  Intravenous  or  even 
subcutaneous  injection  of  human  blood-serum  have  brought  re- 
lief. The  adult  dose  is  15  cc.  of  fresh  serum  (less  than  two 
weeks  old)  if  injected  intravenously,  or  30  cc.  subcutaneously. 
Diphtheria  antitoxin  or  other  serum  may  be  used  in  emergency. 
Directions  for  transfusion  are  given  in  Appendix   (4). 

(12)  Rachitis.     Treatment,     (p.    109.)     Thyroid    extract    improves    the 

general  condition,  growth  and  development  of  a  number  of  ra- 
chitic children  who  are  backward. 

(13)  Syphilis.     Symptoms,     (p.    118.)     According    to    Graves    the    sca- 

phoid type  of  scapula  may  be  an  indication  of  hereditary  syphilis. 
See:  "The  Scaphoid  Scapula  a  Frequent  Anomaly  in  Develop- 
ment, of  Hereditary  Clinical  and  Anatomic  Significance."  (Med. 
Rec,  May  21,  1910.)  "The  Clinical  Recognition  of  the  Scaphoid 
Type  of  Scapula  and  Some  of  Its  Correlations."  {Jour.  Am. 
Med.  Assn.,  July  2,  1910.) 

(14)  Syphilis.    Diagnosis,     (p.   120.)     Since  the  discovery  and  accept- 

ance of  the  spirochaeta  pallida  as  the  cause  of  syphilis,  detection 
of  the  organism  with  the  microscope  is  an  important  means  of 
diagnosis.  The  simplest  method  is  Burri's.  The  sore  is  washed 
with  salt  solution.  Then  the  secretion,  scraped  from  the  sore, 
bloodfree,  is  mixed  with  equal  quantities  of  distilled  water  and 


;50  APPENDIX 

Chinese  ink.  The  mixture  is  smeared  on  a  slide,  allowed  to  dry, 
and  examined  with  oil-immersion  lens.  The  spirochsetes  show 
white  against  a  dark  background. 

(15)  Syphilis.     Treatment,     (p.    124.)     Dioxydiamidoarsenobenzol,    sal- 

varsan  or  "  606,"  which  is  an  extraordinarily  active  remedy  for 
improving  the  clinical  condition,  at  least  temporarily,  in  certain 
cases  of  lues  in  adults,  appears  to  be  dangerous  in  large  doses  in 
infants  with  the  congenital  form,  in  whom  the  spirochsetes  are 
so  numerous  that  their  destruction  may  lead  to  fatality  by  endo- 
toxin; though  many  clinicians  report  excellent  results  when  used, 
intravenously,  in  doses  of  about  o.oi  gram  per  kilogram  of  body 
weight.  Great  caution  should  certainly  be  exercised  in  its  em- 
ployment. In  older  children,  that  is,  in  the  late  manifestations 
such  as  keratitis,  untoward  effects  have  not  been  so  serious ;  nor 
have  curative  effects  been  so  much  more  rapid  than  by  mercury 
and  iodides. 

(16)  Septicemia.     Opsonic  power  of  infants'  blood,     (p.  129.)     Accord- 

ing to  Tunnicliff's  experiments,  the  anti-infectious  power  of  the 
blood  (as  measured  by  the  opsonic  index)  and  the  phagocytic 
power  of  the  leucocytes,  in  infancy  is  far  below  that  of  adult 
blood.     (Jour.  Infect.  Dis.,  Oct.  25,  1910.) 

Vaccine  Therapy.  Da  Costa :  "  The  Routine  Use  of  Autog- 
enous Vaccines."  {Jour.  Am.  Med.  Assn.,  May  28,  1910.)  Mar- 
tin :  "  Vaccine  Therapy  in  Acute  Infections."  {N.  Y.  Med.  Jour., 
Dec.  10,  1910.) 

(17)  Operations    Upon    Tendons.     Open    vs.    subcutaneous    tenotomy. 

(p.  172.)  There  is  no  doubt  that,  to  avoid  the  occasional  in- 
stances of  faulty  union  or  subsequent  stretching  of  the  scar 
tissue,  it  is  better  to  lengthen  by  open  method,  retaining  tendon 
tissue  throughout  all  tendons  that  are  expected  to  functionate. 
Experience  demonstrates  occasional  even  if  rare  failure  of  union 
or  later  stretching  of  the  fibrous  tissue  formed  between  the  sev- 
ered ends  where  no  true  tendon-tissue  intervenes.  In  the  Hibbs- 
Sporon  method,  redundant  length  of  tendon  after  splitting  does 
no  harm.  It  is  merely  folded  within  the  sheath  and  the  sheath 
closed  and  sutured  over  it. 

(18)  Knock-knee.     Osteotomy,     (p.    186.)     As    to    choice    of    inner    or 

outer  side  of  the  limb,  it  is  true  that  by  cutting  on  the  concave 
side  (McCormac)  the  act  of  fracturing  releases  instead  of  tight- 
ening upon  the  osteotome;  and  that  there  is  a  lengthening  rather 
than  a  shortening  of  the  bone. 

(19)  Osteoclasis,     (p.   193.)     Osteoclasis  may  sometimes  be  performed 

by  the  manual  strength  of  the  surgeon  by  pressing  the  limb  sud- 
denly across  the  wedge-shaped  wooden  block  of  Konig,  or  better 
still  the  metal  fulcrum  of  the  author  (see  Fig.  287). 

(20)  Ankylosis,    Arthroplasty.     (Chap,   viii,   p.    198.)     Utilizing   certain 


APPENDIX  y^i 

embryologic  and  pathologic  facts  concerning  the  formation  of 
joints  (see  Section  on  Fasciae  and  Fat  Tissues)  and  the  pioneer 
work  of  Verneuil,  OlHer,  Helferick,  Lentz,  Foederl,  Nareth,  and 
Chlumsky  (see  brief  resume  by  Neff:  Surg.,  Gynec.  and  Obst., 
Nov.,  1912,  p.  529),  Murphy  (Jour.  Am.  Med.  Assn.,  1905,  pp. 
1573-1671 ;  Trans.  Amer.  Surg.  Assn.,  1906,  xxii,  p.  315)  has  suc- 
ceeded in  constructing  joints  both  experimentally  and  clinically 
by  opening  the  capsule,  separating  the  articulating  surfaces  when 
ankylosed,  rounding  them  to  fit  perfectly,  shortening  their  ends 
enough  to  secure  free  room  to  prevent  too  much  pressure,  and  then 
turning  in  flaps  of  fascia  and  fatty  tissue  ample  to  cover  and 
separate  the  articulating  surfaces.  The  flaps  are  sutured  in  posi- 
tion with  chromic  gut,  or  where  not  between  articulating  surfaces 
with  fine  phosphor-bronze  wire  of  eight  strands,  and  the  wound 
is  closed.  The  most  rigid  asepsis  is  necessary,  the  bones  not 
being  touched  with  hands ;  nor  should  the  flaps  be  traumatized. 
The  joint  is  immobilized  for  two  weeks  with  sufficient  extension 
to  prevent  pressure  on  the  inter-articular  flaps.  Then  passive 
and  active  movements  are  used,  and  systematic  exercise  persisted 
in  for  months.  Arthroplasty  has  its  best  field  in  ankylosis  from 
non-tubercular  causes.  A  year  or  more  should  elapse  after  a 
positive  cure  of  joint  tuberculosis  before  it  is  attempted. 

(21)  Joint  Tuberculosis,  (p.  225.)  Our  views  on  the  pathology  of 
joint  tuberculosis  may  have  to  undergo  a  change  if  the  theories 
recently  propounded  by  Ely  are  proven.  As  he  says  in  the 
preface  to  his  book  (Joint  Tuberculosis)  after  recounting  his 
researches,  "  even  many  of  the  facts  seemingly  well  established, 
such  as  the  coagulation  of  fibrin  in  tuberculous  joints  appeared 
impossible."  After  reviewing  the  familiar  teaching  concerning 
the  battle  of  the  lymphocytes  against  the  tubercle  bacilli,  he  says 
(p.  ^y),  "Viewed  in  this  light,  joint  tuberculosis  is  the  result  of 
nature's  effort  to  rid  herself  of  the  disease,  and  is  essentially  an 
excretory  process ;  but  on  this  theory  many  phenomena  of  tuber- 
culosis cannot  be  satisfactorily  explained  —  why,  for  instance,  the 
tubercle  bacillus  can  thrive  in  a  tissue  rich  in  cells  which  are 
supposed  to  be  intended  for  its  destruction,  while  in  other  tissue, 
such  as  yellow  marrow  and  muscle,  it  cannot  exist  unless  there 
be  a  secondary  infection.  On  this  theory,  also,  the  cure  of  a 
tuberculous  joint  after  operation  would  be  hard  to  explain,  for 
the  very  tissue  that  is  supposed  to  be  rich  in  elements  for  destroy- 
ing tubercle  bacilli  disappears.  Without  seeming  to  be  rash,  I 
would  propose  the  following  hypothesis.  The  accepted  relation 
of  the  lymphocyte  to  the  tubercle  bacillus  is  at  least  not  invariable. 
If  we  may  assume  a  different  one,  the  whole  problem  of  the 
occurrence  of  the  tuberculosis  in  the  joint  and  in  some  other 
tissues  becomes  a  simple  one.  .  .  .  Let  us  assume  that  the  lympho- 
cytes and  certain  other  similar  cells  are  not  nature's  defensive 
organism,   but  the   natural   food   of  the   tubercle   bacillus.    The 


752  APPENDIX 

bacilli,  floating  in  the  blood,  are  thrown  out  into  the  various 
tissues  where,  if  the  bacilli  find  cells  suitable  for  their  growth, 
they  live;  where  they  do  not  find  these  cells,  they  die.  Nature's 
protective  mechanism  is  only  the  elaboration  of  toxins  and  the 
production  of  fibrous  tissue.  The  relation  of  the  tubercle  bacillus 
to  the  lymphocyte,  in  other  words,  is  the  same  as  that  of  the 
gonococcus  to  the  polymorpho-nuclear  or  of  the  malarial  Plas- 
modium to  the  red  cells.  An  operation  that  causes  the  disappear- 
ance of  red  or  cellular  or  lymphoid  marrow  in  the  ends  of  the 
bones  shuts  off  the  food  supply  of  the  bacilli.  The  bacilli  can 
find  no  food  in  yellow  marrow,  but,  if  a  secondary  infection  be 
added,  the  resulting  suppuration  furnishes  the  supply  of  cells 
peculiarly  adapted  to  the  growth  of  the  tubercle  bacilli,  and  tuber- 
culosis invades  the  yellow  marrow  also.  I  will  carry  the  theory 
no  further;  to  me  it  appears  to  explain  almost  everything.  .  .  ." 

(22)  Status    Lymphaticus,     Etiology,     (p.    323.)     Basch,     Wien.    Klin. 

Wochenschr.,  1903,  xvi,  893;  Zeitschr.  f.  exper,  Path,  u,  Therap, 
1905-6,  ii,  195 ;  Jahrh.  f.  Kinderheilk.,  1906,  Ixiv,  285 ;  1908,  Ixviii, 
649.  Klose:  Arch.  f.  Kinderh.,  1910,  ix,  i.  D'Oelsnitz :  Arch,  de 
Medecine  des  Enfants,  Paris,  March,  xiv.  No.  3,  pp.  161-240. 

Pathology.  Marfan:  Archives  de  Medicine  des  Enfants, 
Nov.,  1910. 

(23)  Status  Lymphaticus.     Diagnosis,     (p.  324.)     Ferrand  and  Chatelin 

(Bulletin  de  la  Societe  de  Pediatrie,  Paris,  April  13,  191 1)  show 
the  value  of  radioscopy  in  the  diagnosis  of  enlarged  thymus.  See, 
also,  Boggs  (N.  Y.  Med.  Jour.,  July  8,  191 1)  on  percussion  signs 
of  persistent  and  enlarged  thymus. 

Treatment.  Thymectomy  is  also  now  an  established  pro- 
cedure. The  Roentgen  rays  are  used  for  reducing  the  size  of 
the  thymus. 

(24)  Fractures  of  Skull,     (p,  342,)     Nothing  said  in  the  text  should  be 

understood  as  favoring  delay  of  operation  in  cases  of  depressed 
fracture  or  intracranial  hemorrhage  or  compression. 

(25)  Hydrocephalus.     Drainage,     (p.   354.)     Gushing   drained   into   the 

subperitoneal  space  by  trephining  through  the  body  of  the  fifth 
lumbar  vertebra  and  entering  the  spinal  canal.  Half  the  length 
of  the  metal  tube  was  then  introduced.  The  spinal  canal  was 
then  opened  posteriorly  and  the  other  half  of  the  tube  joined  to 
the  first  half.  The  tube  was  left  in  place  to  maintain  a  perma- 
nent opening. 

Andrews  used  successfully  a  glass  tube  for  drainage  into  the 
sub-dural  space.  (Quar.  Bull.  N.  W.  Univ.  Med.  School,  Vol.  xii, 
No.  4,  April,  191 1. 

Ballance's  operation  (as  illustrated  on  p.  359)  is  for  perma- 
nent drainage  of  the  lateral  ventricle.  The  operation  for  per- 
manent drainage  of  the  fourth  ventricle  is  Parkins'  operation. 

(26)  Operations  Upon  the  Cranium.     Wound  infection  and  its  preven- 


APPENDIX  753 

tion.  (p.  364.)  Crowe  advises  the  administration  of  urotropin 
in  all  cases  in  which  meningitis  is  a  possible  complication,  or  even 
if  meningeal  infection  has  already  occurred.  He  claims  the  drug 
begins  to  appear  in  the  cerebro-spinal  fluid  in  a  half  to  one  hour 
after  its  administration;  and  that  it  is  capable  of  deferring  or 
preventing  growth  of  organisms.  (Johns  Hopkins  Hosp.  Bull., 
April,  1909.) 

(27)  Deformities  and  Diseases  of  the  Ear.     (Chap,  xiv,  p.  369.)     Syphi- 

litic Disease  of  the  Ear.  The  exact  pathology  of  the  ear  in 
hereditary  lues  is  still  under  discussion  as  to  whether  it  is  a 
primary  labyrinthitis,  affecting  both  vestibule  and  cochlea;  or 
hemorrhage  into  the  labyrinth,  secondary  to  syphilitic  arteritis; 
or  interstitial  inflammation  of  the  acoustic  nerve,  accompanying 
luetic  inflammation  of  the  meninges.  (See  an  excellent  article 
by  Fraser,  Jour.  Laryng.,  Aug.,  1909.)  Usually  there  are  other 
characteristic  manifestations  such  as  interstitial  keratitis  and 
Hutchinson's  teeth.     (See  Hereditary  Syphilis.) 

Symptoms  appear  from  the  sixth  to  the  fifteenth  year,  with 
catarrh  of  the  Eustachian  tube  and  behind  the  tympanic  mem- 
brane, which  is  lustreless  and  indrawn,  and  sudden  and  usually 
bilateral  deafness.     Treatment  is  that  of  hereditary  syphilis. 

(28)  Birth     Palsies     Non-central.     Treatment,     (p.     395.)     See,     also, 

Clark,  Taylor  and  Prout:  "A  Studyof  Brachial  Birth  Palsy" 
(Am.  Jour.  Med.  Sci.,  Oct.,  1905);  Taylor:  "Results  from 
Treatment  of  Brachial  Birth  Palsy "  {Jour.  Am.  Med.  Assn., 
Jan.  12,  1907.) 

(29)  Poliomyelitis.    Etiology,     (p.  395.)     The  causative  agent  has  been 

proven  to  be  an  ultra  microscopic  organism  of  great  virulence. 
It  resists  freezing,  drying  and  glycerinization. 

(30)  Poliomyelitis.    Diagnosis,     (p.    398.)     Examination    of    fluid    ob- 

tained from  the  spinal  canal  by  lumbar  puncture  may  aid  in  the 
diagnosis.  In  poliomyelitis  it  shows  an  excess  of  lymphocytes, 
but  no  Diplococci  intracellularis  of  Weichselbaum  (the  specific 
germ  of  cerebro-spinal  meningitis). 

(31)  Poliomyelitis.     Treatment,     (p.  399.)     Cushing  and  Crowe  showed 

that  hexamethylenamine  may  be  recovered  in  the  cerebro-spinal 
fluid  in  quantity  having  a  degree  of  antiseptic  power.  Flexner 
and  Clark,  after  suggestion  by  R.  S.  Morris  and  others,  experi- 
mented with  the  drug  in  poliomyelitis,  finding  that  in  monkeys, 
it  had  power  to  prolong  the  incubation  period  (from  6  or  8  to 
24  days)  and  the  onset  of  paralysis  was  prevented.  Power  to 
restrain  an  already  established  infection  has  not  been  shown. 
(Flexner  and  Clark:  Jour.  Am.  Med.  Assn.,  Feb.  25,  191 1.) 

(32)  Operations  upon  Nerves.    Division  of  Posterior  Nerve  Roots,     (p. 

416.)  Forster  has  devised  a  method  for  relieving  the  spasticity 
by  section  of  each  alternate  posterior  root  or  even  more  of  them, 


754     .  APPENDIX 

in  the  affected  area.  Cutting  the  sensory  root  prevents  the  reflex 
contraction  without  diminishing  the  motor  power;  but  as  muscle 
groups  are  usually  innervated  from  three  segments  of  the  cord 
the  reflex  tonus  is  not  completely  destroyed,  but  only  lessened. 
The  operation  is  more  suitable  and  more  successful  in  paralysis 
of  the  lower  extremities,  than  higher.  The  nerve-division  is 
made  after  unilateral  or  bilateral  laminectomy.  Operations  on 
this  plan  have,  in  quite  a  number  of  instances,  given  very  en- 
couraging results.  They  should  only  be  undertaken  after  careful 
study  as  to  which  nerves  are  implicated  and  their  point  of  origin, 
which  is  higher  than  their  point  of  emergence  from  the  spinal 
canal.  Each  nerve  should  be  identified  by  sterilized  electrode 
before  it  is  divided.  (Forster  u.  Tietze :  Zeitsch  f.  Orth.  Surg., 
Oct.  22,  1908,  xxii ;  Mittheil  a.  d. :  Grenzgah.  der  Med.  u.  Chir., 
1909,  Vol.  XX ;  Gottstein:  Berl.  Klin.  Woch.,  April  26,  1909;  Spil- 
ler  and  Frazer :  Univ.  Penn.  Med.  Bull.,  xxii,  Amer.  Jour.  Med. 
.  Sci.,  April,  1910;  Clark  and  Taylor:  A''.  Y.  Med.  Jour.,  1910,  xci ; 
Taylor:  Ann.  Surg.,  1910;  Spitzy:  Wien.  Klin.  Woch.,  Nov.  18, 
xxii,  No.  48,  pp.  1585-1622;  Large:  Arch.  Pediat.,  Nov.,  1910.) 

(33)  Spine,    Lateral    Curvature.     Classification,     (p.    427.)     The    fore- 

going description  of  the  varieties,  may,  like  that  of  some  other 
writers,  lack  clarity,  and  difference  of  terms  is  confusing.  Stated 
in  other  words,  we  have  two  general  classes,  (i)  the  functional, 
postural  or  habitual,  and  (2)  the  structural  or  fixed  curvatures. 

(34)  Lumbar  Lordosis,     (p.   429.)     Among  the  common  causes   should 

be  placed  paralysis,  or  more  often  simply  weakness  or  relaxation 
of  the  abdominal  muscles  and  their  aponeuroses,  and  this  some- 
times associated  with  a  general  enteroptotic  condition. 

(35)  Pott's     Disease.     Paralysis,     (p.    441.)     While    usually    paralysis 

does  not  occur  until  the  disease  is  so  far  advanced  as  to  present 
other  symptoms  including  kyphos,  it  may  in  some  cases  precede 
any  perceptible  deformity. 

(36)  Caries  of  Spine.  Treatment.  The  Calot  jacket,  (p.  446.)  In 
applying  a  jacket  by  this  method  there  is  a  sling  of  muslin  under 
chin  and  occiput  by  which  the  child  is  raised  so  that  his  heels 
do  not  touch  the  floor.  He  wears  one  or  two  buttonless  shirts,  or 
preferably  seamless  stockinet  tubes,  one  of  which  reaches  over  his 
head,  having  a  hole  cut  for  his  nose.  If  there  is  to  be  a  "  military 
collar,"  felt  of  that  shape  and  extending  down  onto  shoulders  is 
sewn  onto  the  shirt  and  for  the  "grand"  jacket  felt  is  applied 
under  the  chin  and  occiput.  A  pad  of  cotton  an  inch  thick  pro- 
tects sternum  and  anterior  ribs,  and  felt  is  placed  over  iliac  crests 
and  sacrum.  Plaster  is  now  applied  and  molded  carefully,  espe- 
cially about  pelvis,  shoulders,  and  neck,  leaving  the  ears  free. 
Not  only  are  roller  bandages  used  circularly,  but  aprons  and 
extra  pieces  made  of  3  or  4  thicknesses  of  crinoline,  the  meshes 


APPENDIX 


755 


filled  with  creamy  plaster,  are  applied.  The  aprons  are  of  the 
length  of  the  trunk  plus  one-half,  and  in  width,  half  the  circum- 
ference of  the  trunk.  The  front  apron  is  applied  from  sternum 
to  pubes  and  then  the  lower  end  fold  up  over  the  lower  abdo- 
men. The  back  apron  is  split  down  nearly  half  way,  making  two 
tails,  one  of  which  goes  over  each  shoulder,  down  in  front  of 
the  shoulder  and  back  under  the  axilla  of  same  side.  The  "  mili- 
tary "  jacket  has  an  extra  neckpiece  and  the  "grand"  jacket  has 
a  neckpiece  and  one  piece  each  for  chin  and  occiput.  Through 
a  small  hole  cut  over  sternum  the  cotton  pad  there  is  removed. 
After  48  hours  the  jacket  is  cut  out  in  front,  exposing  the  lower 
two-thirds  of  sternum  and  the  upper  half  and  median  one-third 
of  the  abdomen  in  one  opening.  A  window  of  6  by  3  inches  is 
cut  out  of  the  back  over  the  kyphosis,  and  the  shirt  is  slit  open 
by  two  cuts  crossing  in  the  middle.  The  skin  is  greased  with 
vaseline  and  pieces  of  cotton  batting  about  the  size  of  the  win- 
dow are  tucked  in  under  the  shirt  by  means  of  a  spatula,  thus 
pushing  the  kyphosis  forward.  The  shirt  is  replaced  and  the 
opening  covered  with  plaster  bandages.  The  kyphosis  is  treated 
thus  again  after  a  couple  of  months.  Calot  claims  to  effect  con- 
siderable straightening  of  the  kyphosis.  If  the  disease  is  located 
above  the  seventh  dorsal  vertebra  or  if  at  any  point  with  para- 
plegia present,  he  uses  the  "  grand "  jacket,  in  other  cases  the 
"  military  "  jacket.  Whether  or  not  straightening  of  the  kyphosis 
is  wisely  or  successfully  attempted,  this  jacket  certainly  forms  an 
effective  apparatus  for  fixation. 

Roberts'  device  for  applying  plaster  jacket.  Roberts  has  a 
simple  and  ingenious  method  of  securing  a  degree  of  straighten- 
ing while  applying  jacket,  by  placing  the  patient,  supine,  with 
the  kyphosis  in  a  muslin  sling,  and  lifting  him  in  the  sling  by 
means  of  an  automobile  jack  having  a  horizontal  bar  above  upon 
which  the  sling  is  hung.     {Jour.  Am.  Med.  Assn.,  March  25,  191 1.) 

(37)  Thymic  Asthma.  Thymic  Tracheostenosis.  Pathology,  (p.  510.) 
For  resume  see  article  by  Warthin  {Arch.  Fed.,  Aug.,  1909),  and 
discussion  by  Holt,  Blake,  Jacobi,  Wyeth,  Rowland,  Ewing,  Nor- 
ris,  Northrup,  Melzer  and  Kerley.  Also  Marfan  {Arch,  de  Mede- 
cine  des  Enfants,  Nov.,  1910). 

Treatment.  Experimental  studies  give  great  promise  of  more 
successful  treatment.  Remarkable  effects  have  been  produced 
upon  the  thymus  in  rabbits  by  the  Roentgen  rays.  See  editorial 
{Jour.  Am.  Med.  Assn.,  Feb.  25,  191 1)  with  reference  to  the 
work  of  Reedberg  of  Upsala  in  1909.  See,  also,  article  by  Rach- 
ford  {Trans.  Assn.  Am.  Phys.,  1910,  xxv).  Several  operations 
for  reducing  the  size  of  the  thymus  have  been  reported  by  Siegel, 
Konig,  Perrucker,  and  Eberhard.  Rehn  made  a  transverse  in- 
cision in  the  suprasternal  notch  through  which  expiratory  efforts 
pushed  out  the  gland.  Rehn,  and  also  Konig,  stitched  the  gland 
to  the  manubrium  sterni.     Marfan  intubates  with  a  long  tracheal 


756  APPENDIX 

canula.  An  increasing  number  of  successful  thymectomies  are 
reported. 

Diagnosis.  On  the  diagnosis  by  radiography  see  Ferrand  and 
Chatelin:  Bulletin  de  la  Societe  de  Pediatrie,  Paris,  April,  xiii, 
No.  4.  It  has  usually  been  taught  that  the  dyspnea  is  worse 
in  the  erect  position,  but  D'Oelsnits  claims  that  it  is  worse  in  the 
recumbent  position,  {Arch,  de  Med.  des  Enfants,  Paris,  March, 
xiv,  No.  3.) 

It  is  not  advisable  to  remove  the  gland  entirely.  Although 
almost  complete  thymectomy  seems  to  have  had  no  deleterious 
late  effects,  its  entire  removal  might  have.  Basch  {Wien.  Klin. 
Wochens.,  1903,  xvi,  893 ;  Zeitsch.  f.  exper.  Path.  u.  Therap., 
1905-06,  ii,  195 ;  Jahrh.  of.  Kinderli.,  1906,  Ixiv,  285 ;  1908,  Ixviii, 
649)  and  Klose  {Arch.  f.  Kinderh.,  1910,  iv,  i)  have  demon- 
strated in  young  animals  extensive  changes  in  the  nutrition, 
especially  of  the  skeleton,  and  of  the  nervous  system,  following 
complete  removal  of  the  thyroid. 

(38)  Empyema.     Treatment,     (p.  521.)     Murphy  advocates  as  curative, 

following  aspiration  in  either  hydro-  or  pyothorax  without 
bronchial  or  external  communication,  injection  into  the  pleural  sac 
of  2  per  cent,  solution  of  formalin  in  sterile  glycerine  mixed  24 
hours  before  using.  A  few  drachms  to  4  ounces  are  injected 
and  this  repeated  every  3  to  6  days.  {Jour.  Am.  Med.  Assn., 
Dec.  18,  1909.) 

(39)  Thoracotomy,     (p.   524.)     The  author's   "rib-stripper"   is   a  most 

convenient  instrument  for  separating  the  periosteum  from  the 
under  side  of  the  rib.  "  It  is  made  of  a  strip  of  flexible  copper, 
18  or  20  gauge  in  thickness,  9  inches  long,  a  quarter-inch  or  more 
wide,  bevelled  at  edges,  and  silver-plated." 

"  It  is  awkward  to  puncture  the  abscess  prematurely  in  the 
act  of  removing  the  periosteum  from  the  under  side  of  the  rib, 
and  have  the  wound  flooded  with  pus  blown  out  forcibly  at  every 
breath  and  cough  before  one  has  completed  the  removal  of  the 
bone.  This  may  be  avoided  and  the  work  facilitated  by  the  use 
of  this  small  instrument. 

"  The  periosteum  is  readily  pushed  off  the  outer  side  of  the 
rib.  Then  the  '  rib-stripper,'  with  a  little  beak  or  elbow  bent 
near  one  end,  is  slipped  under  the  rib  between  periosteum  and 
bone  until  it  emerges  at  the  other  edge  of  the  rib  and  is  drawn 
half  its  length  through.  Both  ends  of  the  instrument  are  then 
brought  together  with  a  slight  pull,  which  bends  it  around  the  rib, 
and  the  looped  instrument  is  slid  first  to  one  angle  of  the  wound 
and  then  the  other,  stripping  the  periosteum  from  the  under  side 
of  the  rib."  ("  Drainage  of  Acute  Pleural  Empyema  in  Chil- 
dren." Kelley:  Am.  Jour.  Surg.,  Jan.,  I9i2.)_  If  ordinary  drain- 
age tubes  are  used,  they  should  be  carefully  secured  from  slip- 
ping  into    the    cavity.     Siphons,   pumping    apparatus    or    suction 


APPENDIX  757 

with  Bier's  cups  are  advised  by  some,  but  are  seldom  if  ever 
necessary  in  children. 

(40)  Fetor,     (p.    525.)     Irrigation    is   used    only    in    case    of   gangrene. 

Fetor  usually  calls  for  freer  opening  or  counter  opening  at  the 
lowest  point  of  the  cavity,  and  search  for  pockets  or  lung  abscess. 
Large  open  cavities  can  be  packed  dry  with  formidine  gauze. 

(41)  Empyema.     Bismuth   paste,     (p.    531.)     Blanchard    {N.    Y.    Med. 

Rec,  May  18,  1912)  uses  a  substitute  for  bismuth  paste  which 
is  non-toxic  and  in  his  experience  equally  efficient.  The  formula 
is  white  wax,  i  part ;  vaseline,  8  parts ;  mix  while  boiling.  In 
badly  infected  cases  iodine  is  added.  For  radiography  he  uses 
33^  per  cent,  of  iron  carbonate  in  white  vaseline. 

(42)  Acute    Peritonitis.     Treatment,     (p.    540.)     Children,    particularly 

young  children,  are  not  always  easily  maintained  in  the  Fowler 
or  any  other  position  constantly,  nor  do  they  usually  submit 
peaceably  to  the  apparatus  for  Murphy's  saline  proctoclysis. 
Consequently  the  prevention  or  the  treatment  of  diffuse  septic 
peritonitis  by  these  means  is  apt  to  be  more  difficult  to  manage 
in  young  children  than  in  patients  of  mature  years. 

(43)  Chronic    or    Recurrent    Appendicitis.     Operation,     (p.    551.)     The 

wet  antiseptic  compress  is  no  longer  used  in  the  interval  between 
the  scrubbings,  but  a  dry,  sterile  protective  dressing  used  instead ; 
and  the  second  scrubbing  may,  if  preferred,  be  replaced  by  a 
coating  of  tincture  of  iodine  applied  to  the  dry  skin  just  before 
the  operation.  Iodine  thus  used  is  an  efficient  antiseptic.  It  can 
be  used  alone,  that  is  without  previous  scrubbing,  in  emergency 
operations.  But  I  prefer  scrubbing.  Its  use  before  laparotomy 
has  been  objected  to  for  the  reason  that  if  the  intestines  come  in 
contact  with  it  in  the  course  of  the  operation  their  peritoneal 
coat  may  be  irritated  sufficiently  to  produce  subsequent  adhesions. 

(44)  Chronic     Non-tubercular     Peritonitis.     Treatment,     (p.     556.)      In 

tapping  the  abdomen  for  this  or  any  other  form  of  ascites  the 
puncture  is  made  in  midline  above  the  bladder.  Local  anesthesia 
with  quinine  and  urea  hydrochloride  is  useful.  A  tiny  cut  is 
made  through  skin  and  fascia  with  a  sharp-pointed  tenotome 
or  cataract  knife.  The  trochar  and  canula  are  introduced,  not 
with  a  sudden  plunge  but  slowly  with  a  slight  boring  motion. 

(45)  Tubercular  Peritonitis.     Treatment,     (p.  561.)     Bradshaw  has  re- 

ported {Arch.  Fed.,  April,  191 1)  a  cure  following  two  operations 
in  a  case  of  dry  non-exudative  tuberculous  peritonitis.  The  pa- 
tient was  eighteen  months  old  and  extremely  ill.  After  opera- 
tion he  improved  greatly,  but  after  five  weeks  relapsed.  A 
second  laparotomy  was  performed,  resulting  in  a  cure  which  had 
lasted  three  years  at  the  time  of  writing.  Judd  reports  (A''.  Y. 
Med.  Jour.,  June  24,  191 1)  operating  successfully  on  twenty-two 
patients,   three   of  whom  were   children,   using   a   modification   of 


7s8  APPENDIX 

Lloyd's  technique.  An  incision  is  made  in  the  right  rectus 
muscle.  The  patient  is  eviscerated  so  far  as  possible.  The  in- 
testines, enveloped  in  hot  moist  towels,  are  thoroughly  washed 
with  a  solution  of  50  per  cent,  of  commercial  hydrogen  peroxide. 
The  abdominal  cavity  is  then  flushed  with  the  same  solution. 
The  peroxide  gives  the  tubercles  a  frosted  appearance.  The 
cavity  and  the  intestines  are  then  thoroughly  washed  with  nor- 
mal saline  solution,  and  the  latter  replaced  in  their  proper  posi- 
tion. The  abdomen  is  closed  with  three  layers  of  sutures.  I 
have  no  experience  with  this  use  of  hydrogen  peroxide. 

(46)  Pyloric  Stenosis.  Treatment.  Hints  on  Food  and  Drugs,  (p. 
567.)  Speaking  generally,  some  modification  of  milk  best  sus- 
tains the  babe  that  must  be  fed  artificially;  and  whey  is  the 
portion  of  the  milk  most  useful,  as  the  irritating  curd  has  been 
removed,  leaving  certain  other  albumins  and  globulins,  sugar, 
and  some  fat.  Additional  sugar,  fat,  or  proteid  may  be  borne  in 
some  cases.  Each  case  of  feeding  is  a  problem  by  itself.  The 
intervals  of  feeding  should  not  be  shorter  than  the  time  necessary 
for  the  stomach  to  empty  itself.  Hyperacidity,  causing  too  rapid 
coagulation  of  proteids,  should  be  counteracted  by  the  addition  of 
limewater  or  sodium  bicarbonate  to  the  food.  (For  excellent  and 
explicit  directions  on  feeding  see  Cotton,  Holt,  Rotch,  Morse, 
Tuley,  Fischer,  Pisek,  Chapin,  and  others.)  The  most  useful 
drugs  are  opium  in  small  doses,  and  belladonna  or,  better,  atro- 
pine. Various  forms  of  opiates  may  be  used.  My  own  prefer- 
ence is  for  the  deodorized  tincture,  minims  ^4o  ^o  ^2- 

Operations  other  than  gastro-entcrostomy.  (p.  568.)  Of 
pylorodiosis  there  are  two  principal  methods,  Hahn's  and  Loreta's. 
Hahn's  method  seeks  to  effect  divulsion  without  any  incision  into 
pylorus  or  stomach.  The  wall  of  the  stomach  is  invaginated  with 
the  end  of  a  finger,  and  the  invagination  upon  the  end  of  the  finger 
is  gradually  thrust  through  the  pylorus.  This  method  is  imprac- 
ticable on  account  of  the  small  size  of  the  parts.  In  Loreta's 
method  a  small  incision  is  made  in  the  stomach-wall  near  the 
pylorus.  The  finger,  or  a  bougie,  or  a  forceps  is  passed  through 
the  wound  and  on  through  the  pylorus,  which  is  thereby  dilated. 
The  incision  into  the  stomach  is  then  sutured  and  the  abdominal 
wound  closed.  This  seems  a  simple  if  rather  unsurgical  pro- 
cedure and  has  had  some  good  results.  But  it  is  not  without 
considerable  danger  of  peritonitis,  is  not  by  any  means  certain 
of  opening  the  passage  sufficiently,  and  is  apt  to  fail  of  per- 
manence. 

Finney's  operation  has  been  advised  by  some.  It  is  siinply  a 
gastr'o-duodenostomy  without  resection  of  the  pylorus.  It  obvi- 
ates the  possibility  of  "  the  vicious  circle,"  which  occasionally 
occurs  after  gastro-enterostomy.  The  lower  wall  of  the  pylorus 
is  folded  up  and  joined  to  the  stomach  and  the  fold  cut  through. 
Of  this   operation,   and   also   of   Nicoll's   ingenious   operation   of 


APPENDIX  759 

pyloroplasty,  it  may  be  said  that  the  attachments  of  the  stomach 
and  of  the  duodenum  are  usually  so  short  that  it  is  difficult  or 
impossible  to  bring  them  into  working  reach,  while  the  small 
size  of  the  parts  and  the  thickened  wall  of  the  pylorus  render 
these  operations  impracticable  for  such  cases. 

(47)  Malformations  of  Colon,     (p.  570).     For  a  good  account  of  idio- 

pathic dilatation  of  colon  (Hirschsprung's  disease)  see  Groves: 
Lancet,  Dec.  11,  1909;  Wilkie:  Edin.  Med.  Jour.,  Sept.,  1909; 
Duval:  Rev.  de  Chir.,  Sept.  10,  1909.  For  an  abstract  of  the 
same,  see  International  Medical  Annual,  1910. 

(48)  Intussusception.    Methods     of     reduction,     (p.      583.)     Zahorsky 

{Arch.  Fed.,  May,  191 1)  describes  a  method  of  treatment  by 
repeatedly  alternating  taxis  and  succussion,  under  anesthesia. 
After  taxis  the  thighs  are  flexed  on  the  abdomen  and  with  rapid 
up  and  down  movement  the  lower  part  of  the  trunk  is  vigorously 
shaken  for  several  seconds. 

(49)  Inguinal  Hernia,     (p.  616.)     The  use  of  the  gypsum  spica  has  been 

abandoned  in  most  cases.  When  used  it  should  be  cut  out  so  as 
to  give  access  to  the  wound  in  case  of  soiling. 

(50)  Hydronephrosis  and  Hydroperinephrosis.     (p.  655.)     Recent  cases 

in  which  the  fluid  has  the  characteristics  of  urine  are  sometimes 
termed  "  uronephrosis,"  reserving  "  hydronephrosis "  for  old 
cases  in  which  the  fluid  has  lost  these  characteristics. 

(51)  Tumors   of   the   Bladder.    Diagnosis,     (p.   670.)     The   bladder   of 

the  child  may  be  examined  by  cystoscope  if  one  has  an  instru- 
ment small  enough.  The  technic  is  similar  to  that  used  in  adults, 
though  anesthesia  is  more  frequently  necessary,  especially  in 
boys.  Also  as  the  bladder  is  rather  an  abdominal  than  a  pelvic 
organ  in  the  very  young  and  is  comparatively  narrow  and  pointed 
at  its  lower  end,  it  is  necessary  to  depress  the  ocular  end  of 
the  cystoscope  to  secure  a  good  view  of  the  trigone  and  posterior 
wall.  Always,  of  course,  the  rectum  should  be  thoroughly 
emptied  beforehand,  and  a  few  ounces  of  fluid  (boracic  solution) 
should  be  introduced  into  the  bladder.  Beer  {Am.  Jour.  Surg., 
March,  191 1)  has  presented  an  improved  cystoscope  for  use  in 
children.  It  is  made  in  two  sizes  with  shafts  gy2  cm.  and  12 
cm.  in  length,  and  15  and  18  millimeters  in  circumference,  re- 
spectively. Each  instrument  is  made  so  that  the  single  catheter 
tunnel  can  be  detached,  thus  having  a  catheterizing  and  an  ex- 
amining cystoscope  in  one.  Both  instruments  admit  a  small  cathe- 
ter, 4-5,  French.     The  optical  parts  are  like  the  Nitze  instrument. 

(52)  Bladder.    Foreign   Body.     (p.   675.)     Instances   are  on   record   o€ 

foreign  bodies  which  had  been  swallowed  entering  the  bladder 
from  the  intestine  by  perforation. 

(53)  Undescended  Testis,     (p.  686.)     Ferguson,  in  his  work  on  hernia, 

describes  a  method  of  dealing  with  undescended  testis  by  incising 


760  APPENDIX 

the  walls  of  the  canal  (tying  the  deep  epigastrics)  to  below  the 
level  of  the  pubic  bone  and  bringing  the  cord  out  at  the  lowest 
angle  of  the  wound. 

(54)  Ovarian    Tumors,     (p.    696.)     See,    also,    an    excellent   article    on 

"  Malignant  Disease  of  the  Uterus,  Ovary  and  Vagina  in  Chil- 
dren," by  W.  A.  Edwards  (Am.  Jour.  Med.  Sci.,  July,  1909). 

(55)  Vulvo- Vaginitis,     (p.    698.)     I    have    seen    a    case    of    malignant 

growth  in  vagina  in  a  child  of  21  months  treated  by  several 
physicians  as  vulvo-vaginitis  because  there  was  a  discharge. 
The  possibility  of  neoplasm  in  this  region  should  not  be  forgotten. 

(56)  Anomalies  and  Deformities  of  Skull,     (p.  399.)     All  the  fontanelles 

should  be  closed  at  or  about  the  eighteenth  month  of  life.  Closure 
of  the  fontanelles  may  be  hastened  in  microcephaly  or  in  heredi- 
tary syphiUs;  or  delayed  in  rachitis,  hydrocephalus,  myxoedema, 
mongoloid,  or  micromelia.  Increased  tension  of  fontanelles  is 
physiological  during  crying  or  straining;  or  is  due  to  hemorrhage 
(see  also  pp.  408,  409),  hyperemia,  hydrocephalus,  intracranial 
tumor,  meningitis,  trombosis  of  longitudinal  sinus.  In  a  less 
degree  it  may  be  present  in  meningismus  during  acute  infections. 
Certain  peculiarities  of  the  infant's  skull  are  mentioned  in 
the  Section  on  Operation  upon  the  Cranium.  Other  abnormalities 
are  handled  in  subsequent  sections  of  the  Chapter  on  the  Head  and 
Brain. 

(57)  Paralyses  of  Infancy  and  Childhood,      (p,  393.)     Among  the  large 

variety  of  these  may  be  mentioned  hereditary  ataxic  paraplegia 
(Friedreich's  ataxia),  the  paralysis  of  amyotrophic  lateral  sclerosis, 
progressive  muscular  atrophy  (Duchenne's  paralysis,  Cruveil- 
hier's  atrophy),  acute  ascending  paralysis  (Landry's  paralysis), 
the  paralyses  of  tumor  of  the  spinal  cord  and  of  syringomyelia, 
myotonia  congenita  (Thomson's  disease),  diphtheritic  paralysis, 
the  birth  palsies,  acute  anterior  poliomyelitis  and  the  cerebral  par- 
alyses, ischemia  and  the  various  forms  of  paralysis  from  pressure 
or  other  traumatism  to  peripheral  nerves  or  nerve  trunks. 

Pseudohypertrophic  muscular  paralysis  is  classed  with  the 
myopathies.  Compression  myelitis  will  be  discussed  under  spinal 
caries. 

(58)  Hydropericardium  and  Pyopericardium.     (p.  531.)     Like  the  pleura 

the  pericardium  may  require  aspiration,  incision,  or  drainage. 
Aspiration  is  made  at  the  left  border  of  the  sternum,  preferably 
in  the  sixth  intercostal  space  or  in  the  fifth  space  by  inclining 
the  needle  slightly  downward.  The  internal  mammary  artery 
should  be  carefully  avoided.  In  pyopericardium  drainage  is  re- 
quired in  the  same  place,  by  open  dissection  resecting  the  sixth 
costal  cartilage  and  fifth  and  fourth  too  if  necessary.  The  internal 
mammary  artery  should  be  tied,  the  muscles  divided,  the  peri- 
cardium nicked,  then  opened,  and  drainage  tube  inserted. 


APPENDIX  761 

(59)  Malformations  of  Rectum  and  Imperforate  Anus.    Presence  of  other 

malformations,  (p.  620.)  In  one  case  with  its  anus  closed  by 
a  membranous  septum  the  infant's  forehead  was  wedge-shaped. 
The  occluding  membrane  had  been  opened  by  Dr.  F.  J.  Morton 
and  the  rectum  was  patulous.  But  the  babe  vomited  whatever  was 
given  it,  though  it  never  vomited  meconium,  and  never  passed 
meconium  from  the  bowels.  Probably  there  existed  other  occlu- 
sion in  the  intestinal  tract.  No  further  operation  was  allowed. 
It  died  on  the  sixth  day  after  birth.     No  post  mortem. 

(60)  Specific  vulvovaginitis.     Dosage  of  Vaccines,     (p.  700.)     A  series 

of  three  to  ten  or  more  injections  may  be  necessary.  The  average 
dose  is  5,000,000,  increasing  5,000,000  to  10,000,000  at  a  dose.  If 
the  dose  does  not  produce  an  abatement  in  the  symptoms  a  larger 
one  may  be  tried.  The  interval  begins  at  five  days,  and  is  grad- 
ually lengthened  to  eight  or  fifteen  days,  as  the  discharge  lessens 
and  becomes  serous. 

(61)  Branchial  Fistulae.    Konig's  Expedient  in  operation,     (p.  721.)     So 

difficult  is  the  complete  removal  of  the  end  of  a  fistula  located 
in  the  depths  near  or  behind  the  pharynx  that  the  ingenious  ex- 
pedient of  Fritz  Konig  is  very  useful.  Konig  separates  the  fistula 
to  a  point  above  the  digastric  muscle,  and  then  proceeds  by  blunt 
dissection  until  he  reaches  the  near  neighborhood  of  the  pharyngeal 
mucous  membrane.  The  mouth  is  then  held  open  with  a  White- 
head gag  and  a  stout  probe  threaded  near  its  end  with  silk  is 
passed  into  the  wound  and  made  to  bulge  into  the  pharyngeal  mem- 
brane in  front  of  the  tonsil.  A  small  incision  made  through  the 
mouth  at  the  bulging  point  admits  the  end  of  the  probe  and  silk. 
The  outer  end  of  the  silk  is  tied  to  the  fistulous  tract  and  the 
latter  easily  pulled  through  into  the  pharynx  and  retained  there 
by  a  few  stitches  which  close  the  wound  in  the  mucosa.  The 
free  end  of  the  fistula  is  then  cut  oiif.  The  external  wound  being 
now  closed,  there  remains  only  a  short  bit  of  fistula  which  opens 
into  the  pharynx  and  does  no  harm. 

(62)  Supernumerary  Auricles.     These   are  rudimentary  auricles  usually 

in  the  form  of  small  projections  or  appendages  composed  of 
cartilaginous  or  fibrous  tissue  or  skin.  They  are  generally  just 
in  front  of,  or  below  the  ear,  or  along  the  line  of  the  anterior 
margin  of  the  sternomastoid.  They  are  branchiogenous  and  may 
accompany  fistulae.  They  may  be  removed  by  clipping  or  dis- 
section. 


INDEX 


Abbott's  method  in  scoliosis,  432 
Abdomen,  anatomy  in  infancy,  532 
examination   of,   533 
malformation   at   linea    alba,   534 
malformation    at    umbilicus,    534 
Abscess,    appendicular,  545 
treatment,    553 
brain   from  ear  disease,  389 

treatment,  392 
extra-dural  from  ear  disease,  389 
in  hip  joint  disease,  237,  242 

treatment,  251 
ischio-rectal,   645 
marginal,   646 
in    pleural    cavity,    515 
post-pharyngeal,    471 
residual,  435 
retro-pharyngeal,  471 

differentiated     from     enlarged 
tonsils,  461 
spinal,   434,   435 

diagnosis,   441 ;    treatment,   449 
tubercular,   225 

reinfection  of,  228 
Abt,   rachitic  teeth,   102 
Achillotomy    for   talipes,   731 
Achondroplasia,  61 
Acromegaly,  61,  94 
Actinomycosis,   148 
Acute   diffuse  cellulitis,   140 
Adenoids,  453 
age,   453 
diagnosis,  455 
effects,  454 
frequency,  453 
in  rickets,   103 
pathology,  453 
symptoms,  454 
treatment,  456. 

after-treatment,  458 
internal,  456 
operative,    456 
Adenomata  in  rectum,  640 
Adhesions,  of  clitoris,  697 
of   labia  minora,  696 
preputial,  680 


Aeroporotomy,  493 
external,  493 
extubation,  501 

digital  expression,  502 
Marfan's  method,  502 
Renault's    method,   502 
instrumental,  502 
internal,  493 
intubation,  493 

advantages  of  external  opera- 
tion, 495 

over  tracheotomy,  494 
after    intubation,   management, 

500 
for  chronic  stenosis  of  larynx, 

504 
disadvantages  of,  495 
for  foreign  bodies,  484 
feeding  after,  500 
history  of,  493 
introduction  of  tube,  498 

laryngotomy,  505 
indications,  505 
instruments,  505 
operative  procedure,  505 
preliminary  tracheotomy,  505 

laryngotracheotomy,  506 

advantages  of  external  opera- 
tion, 495 
after-treatment,   508 
drugs,  509 
nurse's  duties,  508 
operative  procedure,  506 
permanent    removal    of    tube, 

509 
prolonged  intubation,  504 
retained  tube,  504 
tracheotomy,  infra-isthmian  or 

infra-glandular,    509 
uses  of,  493 
Air  passages,  surgery  of,  450 
Albee,  bone-grafting  in  spinal  caries, 

449 
Amboceptor  reaction  in  syphilis,  121 
Amputations  in  compound   fractures, 
273 


;^3 


764 


INDEX 


Amputations — Continued. 

in  hip  joint  disease,  254 

intrauterine,  742 

in  septicemia,   127 
Amussat,  operation  for  anorectal  im- 

perforation,   627 
Amyloid   disease   following   suppura- 
tion, 242 
Anatomy  of  childhood,  54 

.  if  external  auditory  canal,  371 

of  kidneys  in  infancy,  647 

radiographic,  35 

of  rectum  in  infancy,  619 
Anderson,   method   of   tendon   trans- 
planting,  173 
Anemia  in  relation  to  operations,  49 
Anesthesia,  41 

A.  C.  E.  mixture,  41 

in   cheiloplasty,  710 

chloroform,  41 

dangers  of,  40,  41,  49 

ether,  41 

ethyl   chloride,   41 

in  hare  lip  operations,  710 

in   intracranial   operations,  365 

intraneural,  41 

local,  41 

necessity  in  burns,   157,   159 

nitrous  oxide,  41 

in  perineal  proctoplasty,  627 

scopolamine,  41 

semi-anesthesia,  41 

in  shock,  48,  50. 

spinal,  41 
Aneurysm,  cirsoid,  83 
Angina,    Ludwigs,    138,   478 
Angioma,  83 

capillary,  83 

cavernous,    83 

diagnosis,  84 

plexiform,  83 

prognosis,  85 

treatment,  85 
Ankle,  tuberculosis  of,  263 

diagnosis,  263 

prognosis,  264 

symptoms,  263 

treatment,   264 
Ankles,  weak,  739 
Ankylosis,  arthroplasty,   179.   198 
Annandale's  classification,  742 
Anomalies  of  skull,  339 
Antisepsis,  and  antiseptics,  41 

necessity  in  burns,  157 
Antitoxin,  490 

in  diphtheria,  137 


Anus,  atresia  of,  620,  633,  634,  635 
fissure,  644 
fistula,  643 
hemorrhoidal,  645 
imperforate,  see  malformed 
malformed,  621,  630,  631,  633,  634, 

63s 

absent,  rectum  fistulous,  631 
diagnosis,  633 
pathology,  631 
prognosis,  633 
symptoms,  633 
treatment,  633 
absent,   rectum  a  blind  pouch, 
621 
diagnosis,  625 
pathology,  624 
prognosis,  626 
symptoms,   624 
treatment,  626 
abdominal   operations,  629 
infrapelvic   operations,   627 
atresia  ani  urethralis,  635 
atresia  ani  vaginalis,  633 
atresia  ani  vesicalis,  634 
ending  in  a  cul  de  sac,  630 
syphilis  of,  642 

vegetations      or      warts      about, 
642. 
Appendicitis,  540 
diagnosis,  544 
etiology,  540 
bacteria,  541 
concretions,   541 
position  of  appendix,  542 
rarity  in  infants,  541 
operation,  551 

incision,  McBurney's,  551 
incision   simple,   552 
procedure     in     interval     cases, 

552  ^ 

procedure  if  abscess  is  present, 

553  _ 
procedure  if  pus  is  free  in  ab- 
domen, 554 

pathology,   542 

catarrhal,   542 

chronic,  544 

gangrenous,   543 

recurrent,   544 

suppurative,    543 
prognosis,   548 
symptoms,   544 

alteration  of  respiration,  547 

constipation,    546 

frequent   micturition,  547 


INDEX 


765 


Appendicitis — Continued. 

muscular  rigidity,  546 
pain,   544 
pulse,  547 
restlessness,   547 
temperature,  547 
tenderness,  546 
tumor,    546 
tj'mpanites,  546 
vomiting,    546 
treatment,  549 

after-treatment,  554 
necessity  of  early  operation  in 
children,  550 
Appendicular  abscess,  545 

treatment,  553 
Arms,    supernumerary,  741 
Arnsperger,  dermoids  of  ovaries  and 

testicles,  79 
Arteritis,   535 

Arthrectomy   of  knee   for  tuberculo- 
sis, 260 
Arthritis,  acute,  210 
etiology,  211 
symptoms,  211 
treatment,  211 
gonorrheal,  210,  219 
infective  chronic  secondary,  219 
nontubercular,    nonsyphilitic,    216 

secondary,  216 
osteo-arthritis,  219 
rheumatoid,  219 
scarlatinal,  216,  218 

dislocation   from,  218 
traumatic,  215 
tubercular,  of  hip,  237 
typhoid,   216,  218 

dislocation  from,  218 
Arthrodesis,   403 
Arthropathy,  219 

non-inflammatory,  219 
Arthroplasty,    179 

Arthrotomy  of  kuee  joint  for  tuber- 
culosis, 260 
Ashby   and    Wright,    congenital    mu- 
coid cyst,  461 
on  neuroma,  69 
Asepsis,  39,  41 
Aspiration  of  hydronephrotic  tumor, 

657 

of   hydroperinephrotic  tumor,  657 

Asthma,  thymic,  510 

treatment,   511 

Atresia  ani  urethralis,  635 

ani  vaginalis,  633 

ani  vesicalis,  634 


Auditory    canal    external,    anatomy, 

371 
congenital  occlusion,  372 

treatment,  372 
diffused    inflammation   of,  373 
symptoms,  373 
treatment,  373 
diphtheritic    inflammation   of,   374 
foreign  bodies,  372 
treatment,  372 
Auricles,  absence,  369 
eczema,  371 
malformation,    369 
over-development  and  prominence, 

369 
supernumerary,  761 
Auto  inoculation,  raising  opsonic  in- 
dex,  130 
Auto-intoxication    producing     shock, 
49 


Bacher  on  knockknee,  185 
Baginsky's   tonsillotome,   464 
Ballance,       operation       for       hydro- 
cephalus  internus,   359 
Bandage,    Esmarch's,  45 
Plaster  of  Paris,  43 
Bandaging,  42 
Bandy    legs,    188 
Barlow's   disease,    109 
Bassini,  operation  for  femoral  hernia, 
616 

operation  for  inguinal  hernia,  613 
Beck,  operation  for  hypospadias,  679 
Bevan     on     treatment     of     cryptor- 
chidism,   687 
Bigelow^,   litholapaxy,  673 
Bier-Klapp    hyperemia,    127 

conditions  to  be  obtained,  128 
in  localized  tuberculosis,  116 
in    tendon     sheath    inflammation, 

i6g 
method    of    applying,    127 
Bilharzia   adenomata   of   rectum,   639 
Birth  palsies,  393,  408 
Bismuth  paste,  449,   531 
Bladder,   atresia  ani  vesicalis,  634 
calculus,   670 
diagnosis,  671 
etiology,  670 
prognosis,   672 
symptoms,  671 
treatment,    672 
ectopia  vesicae,  663 
extroversion,  663 


y(iG 


INDEX 


Bladder — Continued. 
diagnosis,  665 
pathology,  665 
treatment,  665 
operations,  Konig's,  667 
Maydl's,  668 
Rutkowski's,    667 
Schlange's,   667 
Segond's,  667,  669 
Trendelenberg's,  667 
Wood's,  665 
foreign  body  in,  675 
tumors,    669 
Blake,  chloroform  for  larvae  in  nasal 

passages,   470 
Blanchard,  cases   of  osteoclasis,    193, 

194,  195 
Blood,  in  operations,  38 

examination  in  syphilis,   120 
proportion   to   body   weight,   45 
rapidity  of  loss,  45 
Blood  count,  2)?) 

blood   count   before   operating,  49 
Bloodgood,  blood  count  before  oper- 
ating, 49 
on  shock,  48 
Blood  pressure,  32 
Blood  vessels,  45 

intravenous   injection,  50 
transfusion  of,   747,  749 
Bones  and  joints,  grafting  in  spinal 
caries,  449 
non-tubercular  diseases  of,  198 
tubercular  diseases  of,  223 
Bosses  cranial,  212 
Bouchut,  tubage  of  larynx,  493 
Bovaird   and   Nicoll,  weight  of  thy- 
mus, 323 
Bow  legs,  189 

treatment,   189 
by  braces,  190 
osteoclasis  for,   192 
osteotomy  for,   190 
by   plaster  bandages,    189 
by   splints,  189 
Braces,  43,   184 

for  bow   legs,    190 

for  clubfoot,  731,  732 

for  flat  foot,  733 

for  infantile  paralysis,  401,  402 

Taylor's  for  Pott's  disease,  446 

Washburn's    for    Pott'si    disease, 

446 
for  weak  ankles,  783 
Whitman's  for  fiat  foot,  733 


Bradford    and   Lovett   on   meningitis 

in  Pott's   disease,  444 
Brain,   abscess  of,  from  ear  disease, 
390 

treatment,  392 

operations  upon,  364,  392 

sarcoma  of,  72 
Branchial  cysts,  78 

fistulae,  72a 
Bronchi,  foreign  bodies  in,  481 
Bronchoscopy,  484 
Brophy's  operation,  706 
Brown,  uranostaphylorraphy,  715 
Buck's   extension,   245 
Bull   and   Coley,   relapses   of  hernia, 

613 
Bursae  wounds,  inflammations  of,  180 
Burns  and  scalds,  154 

contractures  from,   159 

dangers,    155 

diagnosis,    156 

pathology,    154 

prognosis,    156 

seriousness  in  children,   154,   157 

shock,  155 

treatment,   157 
Butler,   opsonins,   opsonic  index   and 
vaccine  therapy,    129 

diagnosis     of    syphilis     from    the 
blood,  120 


Calculus,   renal,  657 
urethral,  675 
vesical,  670 

diagnosis,   671 
etiology,  670 
prognosis,  672 
symptoms,  671 
treatment,  672 
litholapaxy,  djz 
lithotomy,   674 
Cancrum  oris,   see  noma,   151 
Canthus,  malformation   of,   721 
Carbolic  acid  gangrene,   149 
Carcinoma,  75 

diagnosis,  'jd 
treatment,  ^y 
Cardiolysis,  53I1  760 
Case-taking,   25 
Cellular  tissues,  180 
Cellulitis,    138 

acute  diffuse,   I40 
common   form   in   children,    138 
diagnosis,   139 


INDEX 


Cellulitis — Continued. 

organisms   producing,    138 
prognosis,    139 

septic,  478 

treatment,    139 
Cephalhematoma,    345 
diagnosis,   346 
etiology,   346 
symptoms,  346 
treatment,  347 
Cephalhydrocele   traumatic,   344 
Cerebri,  prolapsus  and  hernia,  343 
Cheiloplasty,  709 

anesthesia  in,  710 

principles  and  technique,  711 
Chest,   see   thorax 
Cheyne,  tubercular  joints,  236 
Chiene,     cranio-cerebral     topography, 

361 
Chloroform,  41 
Chondro-dystrophia    fetalis,    see 

acondroplasia,  61 
Cicatrices,  in  burns,  159 
Circumcision,  682 
Cirsoid    aneurysm,    83 
Clavicle,  curvature,  197 ;  fracture,  281 
Cleft  palate,  see  hare  lip  and  cleft 

palate,    701 

etiology,    704 

other    operations,    717 

time  for  operation,  705 

uranostaphylorraphy,    713 

varieties,  704 
Clitoris,  adherent,  697 
Club-foot    (see  also   talipes),  722 

bandaging  in,  44 

brace,  731,  732 

shoe,  731 
Club-hand,    740 
Cohnheim,    experiments    with    grafts, 

63 
theory  of  tumor  growth,  63 
Collar      for      immobilizing      cervical 

spine,  447 
Colles'  law  in  syphilis,   117 
Coloboma  of  eyelid,  720 
Colon,  malformation  of,  569 

position  in  infants,  532 
Complement    in    serum    reaction    for 

syphilis,    121 
Complications    of    various    infections 

of  childhood,   147 
Compound   dislocations,   320 
Condylomata,    118 
Congenital    dislocations,    298 


767 

-Continued. 


Congenital    Dislocations- 
fractures,  274 

tumors     of     spinal     and      sacral 
region,  89 
Contractures,  from  burns,   159 
in   clubfoot,   722 
in   paralysis    from    birth    injuries, 

410 
in  poliomyelitis,  397,  399,  400,  401, 

402 
in    pseudo-hypertrophic    paralysis, 

164 
in  tuberculosis  of  ankle,  263 
of   fascia,    179 
of  hips,  238,  239,  240 
of  joints,  230 
of  knee,  256,  259 
Convulsions,  in  tetanus,   143 
Corbin,   sublimed  mercury  for  diph- 
theria, 478 
Corkscrew    and    saber    legs,    189 
Corrective  gymnastics  in  spinal  curv- 
ature, 432 
Cotton,  on  Hodgkin's  disease,  337 
Crampton,     physiologic     age     versus 

chronologic  age,  57,  58 
Cranial  bosses,  212 
Cranio-cerebral   topography,   361 
Cranium,      anatomical      peculiarities, 
366 

fractures,   342 
operations  upon,  364 
pneumatocele,  344 
diagnosis,  344 
treatment,    345 
tuberculosis  of,  270 
Cranio-tabes,  213 

in  malnutrition,  213 
in   rickets,    104,  213 
in  syphilis,   118,  213 
Crico-tracheotomy,  506 
Croup,  diphtheritic,  486 
false,  479 
membranous,  486 
true,  486 
Cryptorchidism,  686 
Curette,  Gottstein's,  457 

Kirstein's,  457 
Cystoma,  89 
Cysts    (see  also  dermoids),  78 

beneath  tongue,  719;  branchial,  720 
hydatid  of  Morgagni,  695 
hydronephrosis,  93 
hydro-perinephrosis,  93 
of  kidneys    92;  of  neck,  720 


768 


INDEX 


Cysts — Continued. 
retention,  91 

causes,    91 

diagnosis,   94 

prognosis,  94 

treatment,  94 
sebaceous,  92 
of  socia  parotidis,  92 
of  spermatic  cord,  695 
of    sublingual    and    submaxillary 

glands,  92 
of    urachus    and    vitello-intestinal 

duct,  94 

Dactylitis,  tubercular,  268 
Deformities,  bow  legs,  189 
clubfoot,    722 
clubhand,    734 

corkscrew  and  saber  legs,  189 
genu  extrorsum,  188 
genu  valgum,  181 
in  Pott's  disease,  439 
of  arm  and  forearm,  197 
of  ear,  369 
of  hands,   735 

of  spine,  426,  429;  of  skull,  339 
of  thorax,  196 
supernumerary   arms,   legs,   hands 

or  feet,  741 
webbed   fingers,  743 
Delavan,    flies    and    larvae    in    nasal 

passages,  470 
Delorme's  operation,  530 
Dermatitis,  42 
Dermoids,  78 

of   ovary,   79,   81,  696 
of  testicle,  80,  689 
Development  and  growth,  54 
Diabetic   gangrene,    150 
Diagnosis,   blood   examination,  32 
difficulties    of,    25 
electricity  in,  34 
laboratory  methods  in,  32 
the  X-ray  in,  34 
Didot,  operation  for  webbed  fingers, 

743 
Differential  blood  count,  33 
Digits,  irregular  alignment  of,  744 
supernumerary,  742 
webbed,  743 
Diphtheria,   135 
diagnosis,    136 
membrane,   135 

membrane  from  other  organisms, 
136 


Diphtheria — Continued. 

mixed  infections  and  results,   136 
prognosis,  137 
pseudo-diphtheria,    135,    136 
symptoms,    136 
toxemia,  136 
treatment,    137 
Diphtheroid,   137 
Dislocations,  298 
congenital,  298 

of  hip  joint,  299 
of   knee,   311 
of  other  joints,  314 j 
of  shoulder,  312 
spontaneous,  218 
traumatic,   314 
compound,   320 
of  hip,  319 
of  patella,   319 
of  penis,  684 
of  phalanges,  319 
of  radius,  314,  316,  318 
of  ribs,  320 
of   shoulder,   319 
of  sternum,  320 
of  thumb,  319 
of  ulna,  314,  316 
Doren,      fallacy     of      Lannelongue's 

operation,  347 
Dowd,    lymph    nodes,    330,    332,    336, 

337 
Drainage  in  hydrocephalus,  353 
tubes  for,  in  empyema,  525 
Dressing,  42 
Dropsy,  of  joints,  225 
Duchenne,  progressive  muscular  pa- 
ralysis, 166 
Duplay's   operation   for   hypospadias, 

680 
Dusting  powders,  42 
Dyspnoea,   in  thymic  asthma,  510 

Ear    disease,    intra-cranial    extension 

of,  389 
Ear  drum,  injuries,  374;  syphilitic,  753 
Ears,   supernumerary,  720 
Ectopia   vesicae,  663 
diagnosis,   665 
pathology,  663 
treatment,  665 
Edema  of  the  glottis,  477 
etiology,    477 
treatment,   478 
drugs,  478 
ice,  479 


INDEX 


769 


Edema  of  the   Glottis — Continued. 
intubation,  479 
malignant,    150 
treatment,    151 
Edwards,    on    sarcoma    of    mediasti- 
num, y2 
Effusion,  character  in  empyema,  520 
early,  520 
late,   520 

in  neglected  empyemas,  520 
Elbow,  tuberculosis  of,  264 
Electricity  in  diagnosis  of  paralysis, 

34 
Electrolysis    for    neoplasms    in    nose, 
452 

for  nevi,  86 

in  tonsillotomy,  462,  464 
Eliot,  suggestion  for  relief  of  intus- 
susception,  590 
Emprosthotonos,  in  tetanus,   143 
Emphysematous   gangrene,    150 
Empyema,   515 

differences    from    adult   type,   515 
double,  531 
effusion,   520 
etiology,  516 

bacteria,    517 
symptoms,   519 
treatment,    520 
drainage,    522 
paracentesis    thoracis,    521 
technique,   521 
uses,  521 
thoracoplasty,  527 

indications    for,    527,    530 
operations — Delorme's,    530 
Estlander's,    528 
Keen's,  529 
Schede's,  529 
thoracotomy,   522 

drainage   tubes,   525 
Flint's  empyema  tube,  525 
for  simple  incision,  522 
indications    for    excision    of 

rib,    522 
technique  of  operation,  523 
Encephalocele,    congenital,    340 
diagnosis,    341 
etiology,  340 
symptoms,   340 
treatment,  341 
Enemata,  after  operations,  51 
Enchondroma,  67 
Enterectomy,  590 
Enterolites,  593 


Enterotomy,   571,   598 

Epicanthus,   721 

Epididymis,  tuberculosis   of,  69O 

Epispadias,  676 

Epithelioma,  75 

rarity,  95 
Epulis,  720 
Erb's  paralysis,   165,  393 

attitude  of  arm  in,  394 

causes,  393 

diagnosis,  394 

prognosis,  394 

treatment,   394 

Kennedy's  operation,  394 
Erysipelas,    137 

diagnosis,  138 

favored  locations,  137 

prognosis,  138 

symptoms,   137 

treatment,   138 
Esophagus,  foreign  body  in,  562 
treatment,  563 

malformation  of,  562 

stricture,  563 
symptoms,  564 
treatment,   564 
Estlander's   thoracoplasty,  528 
Eosinophilia,  34 
Epiphyses,  separation  of,  276 

complications  and  results,  278,  29I 

diagnosis,  277 

of  femur,  lower,  295 

or  fracture   of  olecranon,  292 

and    fracture    at    upper    end    of 
femur,  293 

frequency,  276 

of  humerus,  lower,  285 

of  humerus,  upper,  289 

pathology,  277 

of  radius,  lower,  290 

of  radius,  upper,  291 

of  tibial  and  fibular,  296 

of  trochanter  major,  294 
Epiphysitis,   acute,  210 
etiology,  210 
symptoms,   211 
treatment,  211 

syphilitic,  211 

tubercular,   224,    225 
Epispadias,  676 

pathology,  676 

treatment,  676 

Thiersch's  operation,  677 
Epulis,  720 
Esmarch  bandage,  45 ;  208 


770 


INDEX 


Esmarch  Bandage — Continued. 

in  osteotomy,  i86 

in   sequestrectomy,  208 

in   tenotomy,    172 
Ether,  41 
Ethyl' chloride,  41 
Eyelid,  coloboma  of,  720 

epicanthus,  721 
Examination,  25 

Excision  of  knee  joint  for  tubercu- 
losis, 261 

of  rib,  522 
Exomphalos,  534 
Exploratory  punctures  and  incisions, 

37  ,  , 
Extremities,   malformations   of,   737 
Extroversion  of  bladder,  663 
Extubation,  501 


False  membrane,  in  diphtheria,   135 

from  other  organisms,   136 
Fascia,  contraction  of,  179 

inflammation  of,   178 

injuries  of,   178 
Fasciotomy,  plantar,  402,  730 

in  spastic  paralysis,  413 
Fecal  impaction,  593 
Feet,  supernumerary,  741 
Femur,    fracture    and    separations   at 
upper  end,  293 

fracture  of  shaft,  293 

separations    of    lower    epiphysis, 
295 

separation    of    trochanter    major, 
294 
Ferguson  on  Brophy's  operation,  708 
Fetal  rickets,  see  achondroplasia,  61 
Fetus  in  fetu,  77 
Fever  in  appendicitis,  547 

in  burns,    156 

in  mastoid  disease,  383 

in  noma,   153 

in    sapremia,   125 

in  tetanus,  144 
Fibroma,  64 

upon  gums,  720 

in  nares,  452 

of  tongue,  719 
Fibula,  fracture  of  shaft,  295 

separation  of  upper  epiphysis,  296 
Fingers,  supernumerary,  735 

vi'ebbed,  743 
Fissure  of  anus,  644 
Fissures    syphilitic,    118 


Fistula  in  ano,  643 

in  auris  congenita,  370 
from  Meckel's  diverticulum,  534 
Fistulse,  branchial,  720 
Flatfoot,  725,  726 

with  bow   legs,    189 
with  genu  valgum,  182 
Foreign  body  in  bladder,  675 
in  bronchus,  481 
in  external  auditory   canal,  372 
in  gullet,  470 
in  intestines,  590 
in  larynx,  481 
in  nose,  468 
in  rectum,  590 
in    stomach,    intestine    or   rectum, 

590 

diagnosis,  592 

symptoms,  591 

treatment,  592 
in  trachea,  481 
in  urethra,  675 
Fractures,  271 

congenital,    274 

diagnosis,  273 

greenstick,  276 

incomplete,  276 

intra-uterine,  274 

peculiarities  in  children,  271 

refracture    for    vicious    union, 
279 

traumatic  separation  of  epiphy- 
ses,  276 

treatment,  273 
of  clavicle,  281 
of  bones  of  foot,  296 
of  humerus,  external  condyle,  288 
of    humerus,    external  epicondyle, 

289 
of  humerus,  internal  condyle,  287 
of    humerus,    internal    epicondyle, 

288 
of  humerus,  near  elbow,  282 
of  humerus,  shaft,  290 
of  humerus,  T  or  Y-fracture,  286 
of    inferior   maxilla,   280 
of  malar  bone,  280 
of  metacarpals,  296 
of  nasal  bones,  279 
of  ribs,  297 
and    separation    of   upper    end    of 

femur,  293 
or  separation   of  olecranon,  292 
of  shaft  of  femur,  293 
of  shaft  of  fibula,  295 


INDEX 


771 


Fractures — Continued. 

of  shaft  of  radius,  291 

of  shaft  of  tibia,  295 

of  shaft  of  ulna,  291 

of  skull,  342 

of  sternum,  297 

of  superior  maxilla,  280 
Funnel  chest,  513 

Galvanism,    for    neoplasms    in    nose, 
452 

for  nevi,  86 

in   Raynaud's  disease,  151 

in  tonsillotomy,  462-464 
Gangrene,   148 

carbolic  acid,  149 

diabetic,   150 

emphysematous,  150 

hemophiliac,    150 

noma,  151 

in  septicemia,   127 

traumatic,  149 

treatment,  151 

tj'phoid,    15a 

varieties  and  causes,  148 
Gastro-duodenostomy,   568 
Gastro-enterostomy,   567 
Gastroscope,  563 
Gavage,  53,  54 
Genito-urinary  organs,  647 
Genuclast,   Goldthwaite's,  259 
Genu  extrorsum,  188 

treatment,   188 
Genu  valgum,  pathology,   181 

treatment,  182 

operative  treatment,    184 
Genu  varum,   188 
Germicides,  42 

Gerster,  swelling  of  fractures,  284 
Gersuny,  axial  rotation  of  rectum  to 

form  sphincter,  628 
Gibney,  method  of  strapping  ankle,  738 
Goldthwaite's  genuclast,  259 
Gonorrhoeal    arthritis,    210-219 
Gottstein's  curette,  457 
Grafts,  cartilaginous,  63 

periosteal,    6^ 
Granulomata  of  larynx,  481 
Growth  and  development,  54 
Guersant,  convulsions  in  cases  to  be 
operated,  :i7 

difficulty    of    operations    in    chil- 
dren, 54 
Gullet,  foreign  body  in,  470 
Cum,   tumor   upon    (sec-   Kpulis),  720 


Gymnastics,      corrective      in     spinal 

curvature,  432 

Hahn,    methods    of   pylorodiosis,   567 
Hand,  clubbed,  740 

supernumerary,  741 
Hare-lip,   etiology  and  varieties,  701 

heredity,  704 

median  hare-lip,  703 

treatment,   705 

treatment,  operative,  709 

anesthesia    in,  40,  710 

principles     and     technique, 

711 

Giraldes'    operation,    711 
Maas'  operation,  711 
Malgaigne's   operation,   710 
Mirault's    operation,    710 
Nelaton's  operation,  710 
preliminary  to   operation,  708 
Headache,  in  intra-cranial  inflamma- 
tion, 391 
Height,  57 
Hematoma,    180 

cephalhematoma,  345 
in  hemophilia,  180 
of  sterno-mastoid,    160 
pathology,  160 
results,  161 
Hematuria,  650 
Hemoglobin,   32,   2>z,   38 
Hemophilia,  96 
gangrene  in,    150 
hematomata  of,  180 
hemorrhage  in,  96,  97 
joint    changes    in,   222 
diagnosis,   222 
treatment,  222 
treatment,   99 
Hemorrhage,    as    a    cause    of   shock, 
46,  47 
control   of,  45 

in  cranio-cerebral  operations,  365, 
^367 

in  hemophilia,  96-97 
in  infant,  45 
of  kidney,  650 
rapidity,    45 
in   scurvy,   no 
umbilical,   536 
Hemorrhoids,  645 
Hepatomphalos,   534 
Hernia,  causes,  598 
cerebri,   343 
diagnosis  of,  608 


772 


INDEX 


Hernia — Continued. 

diagnosis  of  varieties  of  inguinal 

hernia,  609 
diaphragmatic,  601 

diagnosis,  603 

symptoms,  603 

treatment,  603 
femoral,   616 
frequency,  598 
inguinal,  606,  616 

acquired,    608 

congenital,  607 

encysted,  607 

funicular,  607 

infantile,   607 

in  canal  of  Nuck,  607 
irreducible,  599 
lumbar,   617 
post-operative,  617 
relapsed,  617 
strangulated,    599 

diagnosis,  600 

operation  for,  600 

symptoms,  599 

treatment,  600 
traumatic,  617 
treatment,  611 

by  truss,  612 

choice  of  operation,  613 

preparation   for   and   technique 
of  operation,  614 
umbilical,  603 

author's  truss,  605 

diagnosis,  603 

operation  for,  606 

prognosis,  604 

treatment,   604 
vaginal,  617 
varieties,  598 
ventral,  603 
Hibbs'    apparatus,    for    reducing   dis- 
location of  hips,  305 
Hibbs-Sporon     method,     of     tendon 
lengthening,  172 
osteoplasty  for  spinal  caries,  447 
Hill,  tension  of  cerebro-spinal   fluid, 

354,  357 
Hip  joint,  congenital  dislocation,  299 
diagnosis,  301 
etiology,   299 
prognosis,  302 
symptoms,  300 
treatment,   302 

Bloodless     reduction     (Lo- 
renz'  method),  304 


Hip  Joint — Continued. 

Hibbs'  method,  305 
Hoffa's  operation,  303 
Ridlon's  method,  308 
traumatic  dislocation,  319 
Hip  joint  disease,  227 
diagnosis,   243 
etiology,  237 
pain,  238 
pathology,    237 
prognosis,  244 
symptoms  and  course,  238 
abscess,  242 
atrophy,  242 
attitude,  239 
amyloid  disease,  242 
night  cries,  239 
rigidity,  240 
shortening,  242 
swelling,   241 
tenderness,  242 
treatment,  amputation,  254 
of  abscesses,  251 
by  fixation,  244,  247 
by  traction,  244 
combined,   247,  249 
Jordan's   operation,  254 
operative,  252 
double  hip  joint  disease,  255 
Hip  splint,  hospital  long,  249 
leather  or  felt,  248 
Phelps',  250 
plaster  of  Paris,  247 
Ridlon's,  249 
Taylor's,   249 
Thomas',  248 
Hodgkin's    disease,   32>7 
diagnosis,  338 
etiology,    337 
symptoms,  338 
treatment,  339 
Hofifa's  operation,  303 
Holt,  on  acute  arthritis,  210 
diplegia,  410 
paraplegia,  410 
on  joint  tuberculosis,  236 
symptoms  of  paralysis  from  birth 
injuries,   409 
Hot  water  for  nevi,  87,  639 
Horsley,  anesthesia  in  brain  surgery, 

365 
Hueter,  synovial  tuberculosis,  227 
Humerus,    fracture    above    condyles, 
283  _ 

diagnosis,  284 
symptoms,  284 


INDEX 


711 


Humerus — Continued. 

treatment,  284 
fracture  of  internal  condyle,  287 
fracture  of  external  condyle,  288 
fracture    of    internal    epicondyle, 

288 
fracture    of    external    epicondyle, 

289 
fracture  of  shaft,  290 
T   or   Y   fracture,   286 
injuries,   near    elbow,   282 
separation  of  lower  epiphysis,  285 
separation  of  upper  epiphysis,  289 
Hutchinson,    J.,    abdominal    taxis    in 
intussusception,  583 
teeth,    120 
triad,  120 
Hydrencephalocele,  340 
Hydrocele,  691 

in  female,  pathology,  694 

treatment,  694 
in  male,  congenital,  692 

funicular,  693 

infantile,   693 

of  cord,   693 

of  tunica  vaginalis,  694 

treatment,  694 
Hydrocephalus,  acute,  348 
chronic  externus,  348 
chronic  internus,  2^ 

diagnosis,   350 

etiology,  348 

pathology,   349 

symptoms,  350 

treatment,  352 

drainage  into  pleural  cavity, 

354 
drainage   into    spinal   canal, 

354 
drainage     into     subcutane- 
ous tissue,  354 
drainage    (permanent)    into 

sub-dural    space,   354 
lumbar  puncture,  352 
tapping  ventricle,   353 
meningeus,  348 
ventriculorum,   348 
Hydronephrosis,  93,  655 
diagnosis,  656 
etiology,  655 
pathology,  656 
prognosis,  657 
pseudo,   93 
symptoms,  656 
treatment,   657 


Hydroperinephrosis,  655 
Hyperemia,  effects,   128 

in    septicemia,    127 

in   localized    tuberculosis,    116 
Hyperplasia     of     lymph     tissue     of 

pharynx  and  naso-pharynx,  453 
Hypodermoclysis,    50,    51 
Hypospadias,  678 

Beck's  operation,  679 

Duplay's    operation,    680 

pathology,  678 

treatment,  679 

Ignipuncture,  87 

Imperforate  anus,  620 

Infections,    various,    having    surgical 

complications,  147 
Inferior    maxilla,    fracture    of,    280 
Infra-isthmian   tracheotomy,   509 
Intestine,  foreign  bodies  in,  590 
malformations   of,   569 
atresia,  570 
diverticulum,  570 
fecal  fistula,  570 
diagnosis,   571 
prognosis,  571 
symptoms,   570 
treatment,   571 
obstruction  by  dermoids,  82 
operation  for  obstruction,  595 
Intra-cranial    extension    of    ear    dis- 
ease,   389 
brain  abscess,  390 
diagnosis,  390 
extra-dural  abscess,  389 
leptomeningitis,   390 
pachymeningitis,    390 
points  of  entrance,  389 
prognosis,  391 
symptoms,    390 
treatment,  392 
Intra-cranial    tumors,    etiology,    360 

operative    treatment,    360 
Intra-neural  anaesthesia,  41 
Intra-uterine  amputations,  742 

fractures,  274 
Intra-venous    injection,   in   shock,    50 
Intubation,  493 

for    chronic    stenosis    of    larynx, 

504 
Intussusception,  572 
course,  580 
diagnosis,  581 
etiology,  572 
prognosis,  580 


774 


INDEX 


Intussusception — Continued. 
pathology,  572 
spontaneous  cure,  580 
symptoms,  577 

anuria,   579 

loss  of  weight,  579 

pain,    577 

prostration,  579 

shock,    579 

stools,  579 

temperature,    579 

thirst,  579 

tumor,    578 

vomiting,   578 
treatment,   581 

advantages    and    disadvantages 
of   air,   584 

advantages    and    disadvantages 
of  fluids,  585 

amount   of  pressure,  582 

device  of   Forest,  584 

enterectomy,    590 

illustrative  cases,   586 

indications  for  laparotomy,  589 

laparotomy,    589 

methods    of    reduction,    583 

obstacles   to   reduction,   582 

softening  of  bowel,  582 

succussion,  759 

use  of  opium,  581 
varieties,  572 
lodin  test  for  glycogen,  34 
Iodoform  emulsion,  233 

Von   Mosetig-Moorhof's,   209 
Ischio-rectal  abscess,   diagnosis,  645 
treatment,  646 

Jackets,  for  spinal  disease,  444 
Jackson,   esophagoscopy    and   gastro- 
scopy,  563,  592 
tracheoscopy     and     bronchoscopy, 

484,  SI  I 
thymic  asthma,  510 
thymic  tracheostenosis,   324 
Jacobi,  the  sigmoid  and  constipation, 

532 
Jaundice,  in  operation  cases,  38,  49 
Joints,  adhesions  in,  321 

congenital  dislocations,  298 
false,  321 

hemophiliac,  changes  in,  222 
infections  of,  non-tubercular,  non- 
syphilitic,  216 
infections    of,   chronic   secondary, 
219 


Joints — Continued, 

inflammations   of,   see  Arthritis 

laxness  of,  298 

syphilitic  disease  of,  213 

tuberculosis  of,  225 
Joined   twins,   77 
Jordan,  amputation  at  hip,  254 
Juvenile  type  of  paralysis,   165 

Keen,   thoracoplasty,  529 
typhoid  arthritis,  216 
Kennedy's    operation    for    Erb's    pa- 
ralysis, 394 
Keratitis,  interstitial  in  syphilis,    119 
Kidneys,    anatomy,   647 
calculus   in,  657 
diagnosis,  658 
symptoms,  658 
treatment,  658 
cysts  of,  92 
floating,  diagnosis,  648 
etiology,  648 
symptoms,  648 
treatment,  649 
hemorrhage  of,  651 
hydro-nephrosis     and     hydroperi- 
nephrosis,  655 

inflammation  of,  tubercular,   659 
injuries  of,  649 
diagnosis,  650 
etiology,  649 
pathology,  649 
prognosis,  651 
symptoms,  650 
treatment,  651 
malformations  of,  647 
perinephritis,  652 
sarcoma  of,  72 
tumors,  innocent,  660 
malignant,  660 
diagnosis,    661 
pathology,    660 
prognosis,  662 
symptoms,  661 
treatment,    662 
Killian,      direct      laryngoscopy      and 

bronchoscopy,   484 
Kinnear,  case  of  cancrum  oris,   153 
Kirstein  curette,  457 
Klebs-Loeffler   bacillus,    135 
Knee-joint,      congenital      dislocation, 

311 

tuberculosis  of,  255 
diagnosis,  256 
pathology,  255 


INDEX 


775 


Knee-joint — Continued, 
prognosis,  257 
symptoms,  256 

treatment,    by   arthrotomy,   260 
by    erasion     (arthrectomy), 

260 
by   excision,   261 
by   fixation,   257 
local,    257 
by  resection,  261 
by  traction,  259 
Knock-knee,  see  genu  valgum,  181 
Koch,   case   of  angioma,  83 
Konig's  operation,  for  extroversion  of 

bladder,  667;  block,  750 
Kyphosis,  in  rickets,  106,  429 

Langemak,  embryology  of  joints,  179 
Laparotomy     for     peritonitis,     Brad- 

shaw,  757 
Laryngitis,    acute    simple,    479 
membranous,   486 
diagnosis,  489 

identity  v/ith  diphtheria,  486 
prognosis,  488 
surgical    importance,   487 
symptoms,  487 
treatment,    490 
antitoxin,  490 
drugs,  490 
extubation,  501 
indications    for     aeroporot- 

omy,   492 
infra-isthmian   tracheotomy, 

509 
intubation,  493 
laryngotomy,   505 
laryngo-tracheotomy  or  cri- 

co-tracheotomj"-,   506 
permanent  removal  of  tube, 

509 
prolonged  intubation,  504 
spasmodic,   479 
syphilitic,  479 
tubercular,    479 
Larynx,  foreign  bodies  in,  481 
diagnosis,   482 
prognosis,  483 
symptoms,  481 
treatment,  483 

bronchoscopy,  484 
digital  extraction,  483 
endolaryngeal  measures,  484 
external    operation,    485 
inversion  of  patient,  484 


Larynx — Continued, 

intubation,   484 
laryngoscopy,  484 
tracheoscopy,   484 
tracheotomy,   etc.,  485 
intubation     of,    493       (see    also 

aeroporotomy) 
tumors   of,   480 

dyspncea,  spasmodic,  480 
treatment,  480 
granulomata,  481 
papilloma,   480 
Laryngotomy,    505 
Laryngo-tracheotomy,   506 
Lateral    sinus,    infective    thrombosis, 
386 

diagnosis,   387 
prognosis,  387 
symptoms,  387 
surgical  treatment,  388 
Lavage,   53,  54 
Legs,  supernumerary,  741 
Leiomyoma,   69 
Leptomeningitis,    from    ear    diseases, 

390 
Leucocyte    count,   33 
Leucopenia,  34 
Lipoma,  67 
Litholapaxy,   673 
Lithotomy,   supra-pubic,  674 
Little's   disease,   408 
Liver,    location    and    size    in    infants, 

532 
Local  anesthetics,  41 
Lock-jaw,  see  tetanus,  141 
Lordosis,  429 
Loreta,  operation  for  pyloric  stenosis, 

567 
Lorenz'    method,    reduction    of    hip 

joint,  304 
Ludwig's  angina,   138,  478 
Lumbar  puncture,   in   hydrocephalus, 

352 
Lumpy  jaw,  see  actinomycosis,   148 
Lymphadenitis,    acute    septic,    138 
acute  simple,  326 
etiology,   326 
symptoms,  326 
treatment,   327 
simple  chronic  or  sub-acute,  328 
diagnosis,   328 
etiology,  328 
treatment,  329 
syphilitic,  337 
tubercular,   329 


77^ 


INDEX 


Lymphadenitis — Continued. 
diagnosis,  331 
etiology,  329 
pathology,  330 
prognosis,  333 
symptoms,    331 
treatment,  333 
Lymphadenoma,   325,    '^yj 
Lymphangiectasis,   325 
Lymphangioma,  87 
Lymphatic     anemia,    see     Hodgkin's 

disease,  337 
Lymphatic  glands,  primary   sarcoma 
of,  325 

diagnosis,  325 
treatment,    325 
Lymphatism      (status     Ijonphaticus) , 
Z;2Z,    510 
diagnosis,   324 
etiology,  323 
symptoms,  323 
treatment,  324 
Lymphoma,  71 
Lymphosarcoma,  325,  337 
Lymph  varix,  325 


Macewen,  operation  for  genu  valgum, 
185,   186 
pathology    of    sinus    thrombosis, 
387 
IMacroglossia,  718 
Macrostoma,  718 
Macrotia,  369 

Malar  bone,  fracture  of,  280 
Malformations,  59,  60   (see  also   de- 
formities) 
abdomen  at  linea  alba,  534 
abdomen  at  umbilicus,  534 
or  absence  of  auricle,  369 
absence    or    suppression   of  parts, 

achondroplasia,  61 
acromegaly,  61,  94 
anus,   620 

auditory  canal,  372 
atresia  oris,  718 
bladder,  extroversion,  663 
canthus,    721 
cleft    palate,   701 
coloboma    of   eyelid,  720 
ear  external,  369 
encephalocele,  340 
epicanthus,   721 
epispadias,   676 


Malformations — Continued. 

esophagus,  562 

extremities,  "jzi 

extroversion  of  bladder,  663 

general,  59,  60 

giantism,  60 

hare-lip,  701 

hydrencephalocele,    340 

hj^pospadias,  678 

small  intestine  and  colon,  569 

kidney,  647 

macroglossia,    718 

macrostoma,  718 

meatus  auditorius,  372 

meningocele,  340 

microcephalus,   347 

microstoma,    718 

nasal  passages,  450 

pigeon-toe,  731 

penis    in    epispadias,    676 

penis  in  hypospadias,  678 

penis  in  extroversion,  664 

rectum,  620 

supernumerary   arms,   legs,   hands 
or  feet,  735 

sacrum,  417,  423 

skull,  339 

or  absence  of  tongue,  718 

of  thorax,  512 

turbinates,  451 
Malignant  oedema,  150 

causes,  151 
Marie's  disease,  see  acromegaly,  61 
Marsh,  amputation  in  morbus  coxae, 

254 

attitude   in  morbus  coxae,  239 

terminology    of    rheumatoid   arth- 
ritis, 219 
Mason's  mouth  gag,  465 
Mastoidectomy,   384 
Mastoiditis,  382 

diagnosis,  383 

indications    for    operative    inter- 
ference, 384 

xntra-cranial  extension,  389 

mastoidectomy,  384 

pathology,  382 

prognosis,  383 

symptoms,   383 

treatment,  383 
Matas,  contributions  upon  ano-rectal 

imperforations,  627 
Mathews,  fistula  in  ano,  643 
Maxilla,   inferior,   fracture   of,  280 
Maxilla,  superior,  fracture  of,  280 


INDEX 


m 


Maydl's    operation    for    extroversion 

of  bladder,  668 
Mayo,  suture  of  fascia,   335 

tying  flaps   in   cleft  palate  opera- 
tion, 716 
McBurney's  incision,  551 
McCurdy,  case  of  cancrum  oris,  152 
McKenzie's   tonsillotome,  464 
Measurements,  56 
Meatus  auditorius   externus,  371 

inflammations   of,  373 
Meckel's    diverticulum,    fecal    fistula 

from,   534 
Mediastinum,  sarcoma  of,  72 
Membrana   tympani,   incision   of,   380 

inflammation  of,  375 

injuries,    374 
Meninges,       operations      upon,      see 

operations    upon    cranium,    364 
Meningitis,    in    cranial    meningocele, 

341 
following   spinal    caries,   <\\\ 
septic,    from    middle    ear    disease, 

389    . 
traumatic,    in    fracture    of    skull, 

343 
Meningocele,   congenital   cranial,   340 

mistaken   for  nasal  polypus,   452 

traumatic  cranial,  344 
Meningo-myelocele,  419 
Mercurial  stomatitis,  124 
Mercury  in  syphilis,   124 
Meta-carpal      bones,      fractures      of, 

296 
Microcephalus,    347 
Microstoma,   718 
Middle-ear,   inflammation,  375 

causes   and   associated   conditions, 

diagnosis,    j^l^ 

intra-cranial   extension,  389 

prognosis,  378 

sj-mptoms,  377 

treatment,  379 
Morbus  coxarius,  237 
IMorphine    in    intra-cranial     surgery, 

36s 
Morton's   method   of   injecting   spina 

bifida,  422 
Mouth  gag,  Mason's,  465 
Munsch,    dermoids    of    ovaries    and 

testicles,  79 
Murphy,    nerve   transference,  406 
Muscles,    160 

general  pathology,  160 


Myelitis,   acute  transverse,  398 
of   anterior  horns,  395 
in  spinal  caries,  440,  441,  443 

Myofibroma,  see  myoma,  69 

Myoma,  69 

Myositis,   rheumatic,    161 

Myringitis,  375 

Myringotomy,  380 

Myxolipoma,    see   lipoma,  67 

Myxoma,  66 


Nancrede,   technique   of  brain   surg- 
ery, 367,  368 
Nasal    bones,    fracture    of,    279 
Nasal  passages,  malformation  of,  450 
malformations  of  turbinates,  451 
malposition  of  septum,  450 
obstruction  by  soft  palate,  468 
syphilitic    ulceration    of,   451 
treatment,    451 
Neck,  fistulse  and  cysts  of,  720 
Nephritis,  tubercular,  659 
Nerve  transference,  406,  415 

division  of  roots,  753 
Neuroma,  69;  treatment,  70 
Nevus,   72,   83 
hand,  85 
lip,  86 
rectum,    638 
tongue,  719 
Nichols,        preserving        endosteum, 

206 
Nicoll,  operation  for  pyloric  stenosis, 

568 
Night-cries,  in  morbus  coxae,  239 
Nitrous  oxide,  41 
Noma,   151 

diagnosis,  153 
fever   in,    153 
locations,    151 
prophylaxis,   153 
symptoms,    152 
treatment,  153 
Norton,  operation  for  webbed  fingers, 

738 
Nose,  falls  or  blows  upon,  451 
foreign  bodies  in,  468 

animate,  flies,   larvae,  etc.,  470 
diagnosis,  469 
inanimate,    468 
removal,  469 
syphilitic    disease    of,   213 
Nothnagel,  formation  of  intussuscep- 
tions, 575 


77^ 


INDEX 


Obstruction   of   air-passages   by   soft 
palate,  468 
of  bowels,  595 
O'Dwyer,  intubation  of  larynx,  493 
Ogston,  knock-knee,  185,    186 
Olecranon,  fracture  or  separation  of, 

292 
Omphalitis,  534 
Operation,  anemia  in,  49 

duration  of,  48 

general  management  of,  39 

jaundice    in,    49 

nutrition   and   food   before,  38 
preparation  for,  27 

shock  from,  48 

treatment  after,  51 
abdominal,    in    ano-rectal    imper- 

foration,  629 
adenoids,  removal  of,  456 
aeroporotomy,  493 
amputation,  of  hip,  Jordan's,  254 
ano-rectal    imperforation,    626 

infra-pelvic,  627 

abdominal,  629 
appendicitis,    551 
arthrectomy    of   knee-joint,   260 
arthrotomy  of  knee-joint,  260 
brain,    360,    364,    392 
brain  tumors,  360 
cheiloplasty,  709 
circumcision,  682 
cleft-palate,  sliding  flap,  713 

Brophy's,  706 
clubfoot,  729 

Phelp's,    for   clubfoot,   732 
cranial,  364 
cricotracheotomy,  506 
cryptorchidism,  687 
electrolysis,   86,  452,  462,  464 
enterectomy    for    intussusception, 

S9Q 
epispadias,   Thiersch's,  677 

Follin's    (Holmes),    676 
Erb's    paralysis,    Kennedy's,    394 
erasions    of    knee-joint,   260 
esophagotomy,    563 
extroversion   of  bladder,  Konig's, 

667 

Maydl's,    668 

Rutkowski's,  667 

Schlange's,  667 

Segond's,    667,    669 

Trendelenberg's,  667 

Wood's,  665 
excision  or  resection  in  tubercu- 


Operation — Continued. 

losis  of  bones  and  joints,  235 

elbow,  265 

hip,  253 

knee,  261 

ribs,   522 
extubation,  501 
gastroenterostomy,  567 
hare-lip,   710 

Giraldes',  711 

Maas',  711 

Malgaigne's,  710 

Mirault's,  710 

Nekton's,  710 
hernia,   diaphragmatic,  603 

femoral,   Bassini's,  616 

inguinal,  614 

lumbar,   617 

relapsed,  618 

strangulated,  600 

umbilical,  606 
hydronephrosis,  93,  657 
hydroperinephrosis,  93,   657 
hydrocephalus,   Ballance's,  359 

drainage    into    pleural    cavity, 
354 

drainage,  subcutaneous,  354 

drainage  into  spinal  canal,  354 

drainage    into    subdural    space, 

354 

tapping   ventricles,   353 
hypospadias.  Beck's,  679 

Duplay's,   680 
infra-pelvic,   in   ano-rectal   imper- 
foration, 627 
ignipuncture,  87 
intestinal   obstruction,   laparotomy 

for,  571,  595 
intravenous  infusion,  50 
intubation  of  larynx,  493 
intussusception,  Eliot's  suggestion 

for,  589 

enterectomy    for,    590 

laparotomy   for,   589 
parotomy  for  intestinal  obstruc- 

tion,_  571,  595 

for  intussusception,   589 

for   tubercular   peritonitis,   560 
laryngotomy,  505 
laryngotracheotomy,  506 
litholapaxy,    673 
lithotomy,  674 
Ludwig's     angina,     incisions     for, 

139 
lumbar  puncture,  353 


INDEX 


779 


Operation — Continued. 
mastoidectomy,  384 
myringotomy,   380 
nephrotomy,  662 

nerve  translerence  and  suture,  413 
osteoclasis,  192 
osteotomy,   186,   190,  732 
paracentesis  abdominis,  556 

thoracis,  521 

of   tympanic   membrane,    380 
proctoplasty,  627 
pyloric  stenosis,  567 

pylorodiosis    for,    Hahn's,    567 

pylorodiosis    for,  Loreta's,   567 
gastroenterostomy,   567 

Finney's,   568 

Nicoll's,  568 
pyoperinephritis,   655 
rectal  prolapse,  638 
rectal   polypus,  639 
redressement  force  of  knock-knee, 

184 
reduction    congenital    hip-disloca- 
tion, 304 

Hibbs',  305 

Lorenz*,  304 

Ridlon's,  308 
resections,  see  excisions 
retropharyngeal      abscess,      acute, 

473 
retropharyngeal    abscess,    chronic, 

476 
sequestrectomy,  208  • 

sinus  thrombosis,  388 
spina  bifida,  422 

synovectomy  of  knee-joint,  260 
tarsal  osteotomy,  72^ 
tarsectomy,  264 
tendon,    171 

lengthening,     171,     172 

open  tenotomy,   171,   172 

subcutaneous  tenotomy,  171 
(See    also    under    Tenotomy) 

shortening,    173 

suturing,    176 

transplanting,    173 
tenosynovitis,  incisions   for,   167 
tonsillotomy      and     tonsillectomy, 

463 
tracheotomy,    infra-isthmian,    509 
tubercular  lymph  nodes,  removal, 

335 
thoracentesis,  521 
thoracotomy,  522 
thoracoplasty,  527 


Operation — Continued. 
Delorme's,  530 
Estlander's,  528 
Keen's,   529 
Schede's,  529 

thymectomy,    511 

urano-staphylorrhaphy,  713 

webbed  fingers.  Didot's,  738 
Norton's,  738 
Operative     trauma     in     relation     to 

shock,  48 
Opisthotonos  in  tetanus,  143 
Opsonic  index,  129 

auto-inoculation,  133 

technique,   130 
Opsonins,  129 
Orchitis,    infectious,    689 

syphilitic,  691 

traumatic,  611,  689 

tubercular,    690 
Osier,  birth  paralysis,  410 
Osteoarthritis,   etiology,  220 

pathology,   220 

synonyms,   219 

treatment,  220 
Osteochondritis,  118 
Osteoclasis,  192 

in  bow  legs,  190 

in  genu  valgum,  186 
Osteokampsis,   196 
Osteoma,  68 

Osteomyelitis,     acute     infective, 
202 

diagnosis,  205 

etiology,  202 

pathology,  203 

prognosis,  205 

sequestrectomy,  208 

symptoms,  204 

treatment,  206 

acute  simple,  201 
Osteoplasty  in  spinal  caries,  447 
Osteotomy,    186,    190 

in  genu  valgum,  186 

tarsal,  732 
Ostitis,   articular,  of  hip,  22,7 

syphilitic,  213 
Otitis,  media,  375 

syphilitic,   120 
Out-knee,   188 

Ovary,  dermoids  or  tridermic  tumors 
of,  79,  81 

misplacement,  695 

tumors,  diagnosis,  696 
Owen,   anesthesia  in  burns,  40 


78o  INDEX 

Owen — Continued. 

epiphyseal   separations   and   dislo- 
cations, 285 
lancing    retropharyngeal     abscess, 

473 
tongue  swallowing,  471 
redressement  force  in  knock-knee, 

184 
treatment  of  lumbar  hernia,  617 
Oxygen,  in  shock,  50 

Pachymeningitis,    from    ear    disease, 

390 
Palate,  cleft,  701 

malformation    of,    obstructing    air 

passages,  468 
syphilitic  disease  of,  213 
Pain,  appendicular,  544,  545,  548 
badly  borne  when  severe  or  pro- 
longed, 46,  52 
in  bone  tuberculosis,  228 
in     chronic     retropharyngeal     ab- 
scess, 474 
elicited   by    examination,   28 
in  hip-joint   disease,  238 
in  intussusception,  577 
located    inaccurately    by    children, 

205,  545 
occasional   fortitude  under,   29 
in  Pott's  disease,  436 
in    sacroiliac    disease,    266 
Painter,   atrophic   arthritis,  220 
Papilloma,    of   bladder,   669 
larynx,  480 
tongue,  719 
Park,    incubation   period    of   tetanus, 

141 
Paracentesis,    abdominis,   556 
of  ear  drum,  380 
thoracis,  521 
Paquelin  cautery,  40 

for  enlarged  tonsils,  462 
joint   tuberculosis,   232,   257 
neoplasms   in  nose,  452 
nevi,   87,   639 
-  noma,    153 
rheumatic   myositis,    161 
Paralysis,    abdominal    muscles,   537 
acute  or  subacute  acquired,  410 
lesions,  411 
symptoms,  411 
birth,  393,  408 
cerebral,  infantile,  407 

from    birth    injuries,   409 
diagnosis,  409 


Paralysis — Continued. 

symptoms,  409 
from  prenatal  causes,  407 
diagnosis,  412 
diphtheritic,  398 
Erb's,  393 

facial  in  poliomyelitis,  397 
infantile  cerebral,  407 
myelitis,    acute    transverse,    398 
prognosis,     all     forms,     infantile 

cerebral    paralysis,   411 
pseudo,    of   scurvy,    no,  398 
pseudohypertrophic   muscular,    162 
facial   scapulo-humeral   type,    165 
juvenile  or  Erb's  type,  165 
peroneal   type,    165 
prognosis,   165 
progressive  muscular,  166 

treatment,   165 
spastic,  407 
spinal,    398 

spinal,  acute  atrophic,  395 
treatment,  412 

of  cerebral  hemorrhage,  412 
of  contractures,  413 
by   nerve   transference,  413 
prophylactic,   412 
of  resulting  conditions,  413 
Paraphimosis,  683 
Parrot,  cranial  bosses,  213 
Patella,    fractures   of,  296 

habitual   dislocation,   309 
Peters'    wrench,    259 
Penis,  dislocation  of,  684 
constrictions  of,  684 
malformation     of     in     epispadias, 

676 
malformation    of   in    hypospadias, 

678 
malformation   of  in   ectopia  vesi- 
cae, 664 
Pemphigus,   syphilitic,   118 
Perichondrosis,  pseudoparalytic  syph- 
ilitic, 211 
diagnosis,  212 
etiology,  211 
symptoms,   212 
treatment,   212 
Perinephritis,  652 
diagnosis,    652 
etiology,  652 
pathology,  652 
prognosis,  654 
symptoms,  652 
treatment,  654 


Periosteum,   anatomical   peculiarities, 
271 

in  fractures,  272 
in  separation  of  epiphyses,  278 
Periostitis,   198 

acute  suppurative,  198 
diagnosis,    199 
etiologj',    199 
symptoms,    199 
treatment,  199 
osteoplastic,    199 
etiology,   200 
pathology,   201 
syphilitic,   189.  200,  213 
treatment,   201 
Peritonitis,    acute,   537 
diagnosis,  538 
etiology,  537 
pathology,    538 
prognosis,  539 
symptoms,   538 
treatment,  539 
chronic,   non-tubercular,  555 
diagnosis,  556 
pathology,  555 
prognosis,  556 
symptoms,  555 
treatment,  556 
septic,   from   omphalitis,   535 
symptoms,  535 
treatment,  535 
tubercular,  556 
acute  miliary  form,  556 
ascitic    form,    557 
diagnosis,   557 
prognosis,  558 
symptoms,   557 
diagnosis,  559 
fibroplastic   form,  558 
treatment,   general,   559 

operative,  560 
ulcerative  form,  559 
Pes  varus,  722 

Phalanges,    dislocation    of,    319 
fractures  of,  296 
supernumerary,  735 
Pharyngeal   tonsil,  453 
Phelps,  operation  for  club-foot,  732 

hip    splint,    250 
Phimosis,  681 

circumcision    for,   682 
Phlebitis,  535 

Pilcher,   terminology  of  tetanus,    142 
Pigeon-breast,  513 
Pigeon-toe,   744 


INDEX  781 

Plaster  jacket,  43,444;  Calot,  754 
Plaster    of    Paris    bandage,    applica- 
tion of.  43 
removal  of,  44 
Pleurosthotonos  in  tetanus,  143 
Pneumatocele   cranii,   diagnosis,   344 
etiology,  344 
treatment,  345 
Poliomyelitis,    acute    anterior,   395 
diagnosis,  398 

distribution  and  extent  of  paraly- 
sis,  396 
pathology,  395 
prognosis,  399 
symptoms,    396 
results,    397 
types,    397 
treatment,   399 
arthrodesis,   403 
of  ankle,  403 
of  hip,  404 
of  knee,  404 
braces  in,  402 
general,    399 
mechanical,  399 
nerve   transference,  406 
operative,  399 

tendon   transplantation,  405 
Polydactylism,  735 
Polypi,   66,  67,   639 
middle  ear,  67,  382 
nasal,  67,  452 
rectal,  67,  639 
vesical,  669 
Poncet,  method  of  tendon   lengthen- 
ing, 173 
Post-operative   hernia,  617 
Post-pharyngeal   abscess,  471 
Pott's  disease,  434 
abscess  in,  434,  435 
attitude,  438 

compression  symptoms,  441 
deformity,    439 
diagnosis,  436 
etiology,  434  _ 
muscular  rigidity,  437 
nervous  symptoms,  439 
pathology,   434 
prognosis,   442 
symptoms,  436 
treatment,  443,  531 
mechanical,  443 
braces,   446,   449 
collar,  447 
head   extension,  447,  448 


782 


INDEX 


Pott's    Disease — Continued. 
jackets,  444,  449 
rest  and  methods  of  obtaining 

it,  443 
advantages  of,  444 
time  it  should  be  continued, 

443 
Power,  astringents  for  enlarged  ton- 
sils, 461 

hunger   favors  shock,  40 
rectal  polypi,  66 
synovial  membranes  in  relation  to 

epiphyses,   226 
tapping  cystic  hygroma,  89 
Prepuce,  adherent,  680 
Primary    progressive    myopathy,    162 
Proctitis,   640 

Progressive  muscular  paralysis,   165 
Prolapsus,  cerebri,  343 
recti,  636 

urethral,   female,  697 
Pseudo-diphtheria,    135,    136 
Pseudo-hypertrophic     muscular     pa- 
ralysis, 162 
diagnosis,   163 
etiology,    162 
pathology,   162 
prognosis,    165 
sym.ptoms,   163 
treatment,    165 
Pseudo-leukemia,  337 
Pseudo-paralytic   perichondrosis,   21 1 
Pyemia,   134 
Pyloric  stenosis,  564 

classes  and  varieties,  564 
diagnosis  and  symptoms,  566 
etiology  and  pathology,  564 
food  and  drugs,   758 
prognosis,  565 
treatment,  567 
operative,   568 

Finney's  operation,  758 
gastroenterostomy,  568 
Hahn's,     Loreta's,     NicoU's, 

758 
pylorodiosis,  758 
Pyopericardium,   760 
Pyothorax,  515 

Quincke,  lumbar  puncture,  352 

Rachitis,  99 

acute   hemorrhagic,    109 
age  of   incidence,   loi 
craniotabes    in,    104 
deformities    of,    103,    105,    181 


Rachitis — Continued. 
bow   legs,    189 
corkscrew  legs,  189 
forearm,  196 
genu  extrorsum,  188 
genu  valgum,   181 
saber  legs,  189 
spine,  106,  426,  429,  430,  431 
diagnosis,    106 
etiology,  99 
fetal,  61 
lesions,  100 
rosary   of,    104 
symptoms,   loi 
treatment,  107 
Radiography,   35 

Radius,   dislocation  backward,   318 
dislocation  forward,  318 
fracture  of  shaft,  291 
separation  of  lower  epiphysis,  290 
separation  of  upper  epiphysis,  291 
subluxation,  317 
Radius    and    ulna,    dislocation    back- 
ward or  laterally,  314 
dislocation  forward,  316 
Radium  in  treatment  of  nevi,  87 
Ranula,  92 

Raynaud's  disease,  151 
Rectal   abscess    (ischio-rectal),  645 
Rectum,  anato-ny  of,  618 

bilharzia  adenomata  in,  639 
foreign  body  in,  646 
inflammation   of,  640 
diagnosis,  641 
etiology,  640 
pathology,  640 
symptoms,   641 
treatment,  641 
malformations  of,  620 
classification,  621 
diagnosis,  various  species,  621, 

624,  625,  630,  633,  634,  635 
etiology,  620 
symptoms,  various  species,  624, 

633,   634,    635,    636 
treatment,  various  species,  622, 
624,  626,  627,  629,  630,  633 
abdominal    operations,    629, 

63s       _ 
infrapelvic    operations,    627, 

634 
nevus  of,  638 
polypus  of,  639 
prolapsus  of,  636 
syphilis  of,  642 


INDEX 


783 


Rectum — Continued. 

vegetations   in,   642 
Renal   calculus,   657 
Retention  cysts,  64,  91 
Retro-pharyngeal   abscess,  471 
diagnosis,  472 
etiology,  471 
prognosis,  472 
symptoms,  471 
treatment,   472 
chronic,  474 
diagnosis,  474 
etiology,  471 
pain   in,  474 
symptoms,  474 
treatment,   476 
Rhabdomyoma,   see   myoma,  69 
Rheumatic  myositis,   161 
Rheumatoid  arthritis,  219 
Rhinoliths,  468 
Ribs,  dislocation,  320 
excision,  522 
fractures,  297 
tuberculosis,  270 
Rice,   or  melon   seed,   bodies,   228 

in  sublingual  cysts,  719 
Rickets,    see   rachitis,   99 
Ridlon,  hip  splint,  249 

method  of  reducing  dislocation  of 
hip,  308 
Risus  sardonicus,  143 
Rotch,  index  of  anatomic  or  chrono- 
logic age,  56 
Robinson's  tonsil  hemostat,  466 
Rutkowski's   operation   for  extrover- 
sion of  bladder,  667 


Saber  legs,   189 

Sacro-iliac    articulation,    tuberculosis 
of,  266 

diagnosis,  266 

prognosis,  267 

symptoms,  266 

treatment,  267 
Sacrum,    malformation   of,   423 
Saline  solution,  50 

in  hemorrhage  and  shock,  50 

intravenously,  50 

post-operative,  51 
Salvarsan  in  syphilis,  750 
Sapremia,  125 

symptoms,    125 

treatment,  126 
Sarcoma,  71 


Sarcoma — Continued. 
diagnosis,  74 
etiology,  71 
location,    71 
symptoms,  74 
treatment,  75 
varieties,  71 
from  angioma,  85 
of  bladder,  669 
of  brain,  72 
upon  gums,  720 
of  kidney,  72 
of  mediastinum,  72 
in  nares,  452 
Sayre's  jury-mast,  447 
Scalds,  154 
Scapulo-humeral    type    of    paralysis, 

i6s 
Scarlet  fever,  135 

causing   arthritis,   216,   217,    218 

causing  cellulitis,   138 

causing  empyema,  516,  520 

causing   lymphadenitis,   326 

surgical  complications  of  ordinary 
scarlet,    135 

surgical  scarlet  proper,  135 
Schlange's     operation     for    extrover- 
sion, 667 
Schede's   thoracoplasty,   529 
Scoliosis,  424 

Scopolamine-morphine  anesthesia,  41 
Scorbutus,   infantile,   109 

course,  no 

diagnosis,  in 

etiology,   no 

hemorrhages    in,    no 

morbid   anatomy,   no 

results,    III 

symptoms,   no 

treatment,   in 
Scott's   dressing,  232 
Scurvy,  see  scorbutus,  109 
Scrofula,   113 
Selenko-Boborof,  operation  for  spina 

bifida,  422 
Semi-anesthesia,  41 
Senn,   classification    of   tumors,   64 

dermoids  of  testicle,  81 
Segond's   operation   for   extroversion 

of  bladder,  669 
Separation  of  epiphyses,  276 
Septicemia,  126 

gangrene    in,    127 

hyperemia   and  effects,    127 

sources  of  infection,   126 


784  INDEX 

Septicemia — Continued. 

symptoms,  126 

treatment,  127 
Sequestrectomy,  208 
Sherman,  drainage  of  hydrocele  into 

pleura,  354 _ 
Shock,  anesthesia  as  a  cause  of,  48, 
SO 

athrepsia  as  a  cause  of,  47 

in  burns,   155 

diagnosis,  49 

drugs  in,  51 

hemorrhages  as  a  cause   of,  47 

malnutrition  as   a  cause  of,   47 

operative   trauma   as    a   cause   of, 
48 

other  factors  as  a  cause  of,  48 

treatment,  50 
Shoe,  for  clubfoot,  731 
Shoulder,   congenital   dislocation,  312 
treatment,  313 

traumatic   dislocation,  319 

tuberculosis  of,  265 
Sinus,  malformation  of  rectum,  631 

skin-grafting  for  burns,  159 
Skull,  anomalies  and  deformities,  339 

fractures  of,  342 
Smith,    Grieg,    finding    intestinal    ob- 
struction, 596 

J.  Lewis,  on  inhalation,  491 

Thomas,  on  acute  arthritis,  210 
Spastic  paralysis,  407 
Spermatic  cord,  689 
Sphincter  ani,  hypertrophy  of,  620 

inefficiency  of,  646 
Sphygmomanometer,  32 
Spiller  and   Frazier,  nerve  transfer- 
ence, 407 
Spina  bifida,  417 

anterior,  417,  420 

congenital  defect   in,  417 

diflferential   diagnosis,   420 

false   (occulta),  89,  420 

prognosis,  420 

treatment,  421 

by  injection,  422 
by  operation,  422 
by  protection,  422 

true,  418 

varieties  of,  419 
Spinal  abscess,  434 
Spinal  anesthesia,  41 
Spina  ventosa,  268 
Spine,  417 

caries  of,  434 


Spine — Continued. 

treatment,  443,  754 
lateral  or  rotary  lateral  curvature 
of,  424 

causes,  424 

diagnosis,  429 

examination,  429 

frequency  among  girls,  429 

kyphosis,  429 

lordosis,  429 

period  of  occurrence,  425 

prognosis,  430 

rotary  deviation,  427 

treatment,  430 

Abbott's  method,  432 

corrective  gymnastics,  431 
mechanical  support,  430 
rest,  430 
normal  curves  of,  423 

at  birth,  423 

in  fetus,  423 

later   form   of  spine,  424 
surgical  conditions,  417 
tuberculosis  of,  434 
Splints,  43 

for    gradual    extension    of    elbow 

or  knee,  259 
hospital  long  hip,  249 
Phelps'  hip  crutch,  250 
plaster   of   Paris,  247 
Ridlon's  hip,  248 
Taylor's  hip,  249 
Thomas'    hip,    248 

knee,   258 

long  hip,  249 
Volkman's,  296 
Starvation  in   relation  to  shock,  47 
Status  lymphaticus  (lymphatism),  323 
anesthesia  in,  40 
diagnosis,  324 
etiology,  323 
symptoms,  323 
treatment,  324 
Stenosis,   of   esophagus,  563 
of  intestine,  569 
of  larynx,  chronic,  intubation  for, 

504 
diphtheritic,  487 
of  pylorus,  564 
of  trachea  in  thymic  asthma,  510, 

Sii 

Stemo-clavicular    joint,    tuberculosis 

of,  269 
Sterno-Mastoid,  hermatoma  of,   160 
in  torticollis,    161 


INDEX 


78s 


Sternum,  dislocation,  320 

fracture,  297 

tuberculosis  of,  270 
Stoerk's  tonsil  hemostat,  466 
Stomach,  foreign  bodies  in,  590 

washing,   53,   54 
Stomatitis   mercurial,    124 
Stone,  in  bladder,  670 

in  kidnej^  657 

in   urethra,   675 
Strangulation,    internal,   595 

operation      for      obstructicxn      of 
bowels,   595 

symptoms,   595 
Struma,     113 

Subluxation  of  radius,  317 
Superior  maxilla,  fracture  of,  280 
Supernumerary  arms,  legs,  741 

auricles,   721,   761 

digits,   742 

classification,  742 
treatment,   742 

hands  and  feet,  741 

testis,   688 
Suppression   of  extremities  or  parts, 

Suprapubic  lithotomy,  674 
Surgical  complications  of  various  in- 
fections of  childhood,  147 
Suter's    method    of    uniting    tendons, 

177 
Sutherland  and  Cheyne,  operation  for 

hydrocephalus,  355 
Sutton,  on  coccygeal  tumors,  91 
Syndactylism,  'j'^'] 
Synechise  in  nares,  451 
Synovectomy      for     tuberculosis     of 

knee  joint,  260 
Synovitis,  teno-,  acute,  167 

purulent,   167 
Synovitis,   syphilitic,  213 

tubercular,   225 
Syringo  myelocele,  420 
Syphilis,  116 
acquired,    116 
Colles'   law,    117 
condylomata,  118 
cranial  bosses,  212 
cranio-tabes,  118,  213 
diagnosis,   119 

from  blood,  120 
hereditary,   116 
Hutchinson's  teeth,  120 
triad,   120 


Syphilis — Continued. 

interstitial   keratitis,    119 
late  manifestations,  118 
mercurial  stomatitis,  124 
mercury   in,    124 
mother's    immunity,     124 
of  nose  and  palate,  213 
osteochondritis,   118 
ostitis  and  periostitis,  213 
pemphigus,  118 

pseudo-hypertrophic     perichondri- 
tis,- 211 
of  rectum,  642 
symptoms,  117 
synovitis,  213 

diagnosis,   213 

prognosis,  214 

treatment,  214 
of  testicle,  691 
treatment,   124 

of  late  manifestations,  125 

local,  124 

local  for  late  lesions,  125 
and  vaccination,  116 

Talipes,    ']22 

etiology,   722 

prognosi,  728 

treatment,  728 

of  compound  forms,  739 
old  and  new  methods,  728 
(see  also  under  varieties) 

varieties,  722 

calcaneo  valgus,  728 
calcaneus,  726 ;  treatment,  T^G 
cavus,  726;  treatment,  '/'il 
equino-varus  acquired,  727 

treatment,  728 
equino-varus  congenital,  727 

treatment,  728 
equinus,  724 ;  treatment,  736 
neglected    and    relapsed    cases, 

Cook's  operation,  734 
Phelps'  operation,  y^Ty 
tarsectomy,  734 
planus,   726 
valgus,  724 

treatment,  735 
varus,  724 

treatment,  735 
Tarsal  bones,  tuberculosis  of,  264 
Taylor,  brace  for   Pott's  disease,  446 
Teeth,    rachitic,    loi,    102 
syphilitic,    120 


786 


INDEX 


Tendinous   nodules,    rheumatic,    170 
Tendons,  injuries,   170 

lengthening,   171 

shortening,    173 

suturing,  176 

tenotomy,   171 

transplantation,    171,    173,  405 
Tendons  and  their  sheaths,  166 
Teno-synovitis,   167 

treatment,  169 
Tenotomy,  in  club-foot,  729 

in  contractures  of  arthritis,  259 

of  ham-strings,  259,  413 

open  method,  172 

of  peroneals,  402 

in    pseudo-hypertrophic    muscular 
paralysis,  165,  166 

in  spastic  paralysis,  413 

in   spinal  paralysis,  401 

of  sterno-mastoid,   162 
subcutaneous  method,   171 

of   tendo-achillis,   402,   413,    731 

of  tibialis    anticus,  402,   729 

of  tibialis  posticus,  402,  729 

in  torticollis,  162 
Temperature  in  relation  to  shock,  46, 

47 

as  a  symptom,  31 
Teratomata,  TJ 

endogenous,  TJ 

exogenous,  "j^ 
Testicle,  inflammation  of,  689 

syphilitic,  691 

tubercular,  690 

traumatic,  611,  689 

supernumerary,  688 

tumors  of,  689 

dermoids,  80 

undescended,     misplaced,    hidden, 
686 
diagnosis,  686 
pathology,  686 
treatment,  687 
Tetanus,  141 

course  of,  142 

cephalicus,  144 

chronic,  142,  144 

diagnosis,  144 

distribution,   141 

drugs,  147 

facialis,   144 

general  management,  146 

pathology,  141 

prognosis,  145 

prophylaxis,  145 


Tetanus — Continued. 

symptoms,   142 

treatment   with    antitoxin,    146 

treatment  of  wounds,   145 

varieties,   142,   144 
Thiersch's    operation    for    epispadias, 

solution,   antiseptic,  42 
Thomas'   hip  splint,  248 

knee-splint,  258 
Thoracectomy,  prsecardial,  531 
Thoracoplasty,  527 
Thoracotomy,  522,  756 
Thorax,  anatomy  in  childhood,  512 
caries,  514 
deformities,  512 
etiology,  513 
rickety,  196 
treatment,  513 
varieties  of,   513 
empyema,  515 

infective  inflammation  within,  515 
incisions   of,   522 
paracentesis  of,  521 
plastic  operations   upon,  527 
tumors  of,  514 
Thrombosis  of  lateral  sinus,  386 
Thumb,  dislocation  of,  319 
Thymus,  operation  upon,  324,  510 
Thymic  asthma,  510 
Tibia,  fractures  of  shaft,  295 

separation  of  upper  epiphysis,  296 
separation  of  tubercle,  296 
Toes,  irregular  alignment,  738 
supernumerary,  735 
webbed,  "jyj 
Tonsils,   enlarged,  459 
age  of  occurrence,  459 
diagnosis,  460 
etiology,  459 
forms,  459 
in  rickets,  103 
prognosis,  460 
symptoms,  460 
treatment,  461 

after-treatment,  467 

effects    of    removal    on    voice, 

462^ 
local,   461 
medical,  461 
tonsillectomy,   463 
tonsillotomy,  463 
hemorrhage,  465 
hemostat,  Stoerk's,  466 
hemostat,    Robinson's,    466 


INDEX 


787 


Tonsils — Continued. 

instruments,  463 
use  of  anesthetic,  465 
Tonsil,  pharyngeal,  453 
Tonsillectomy,   463 
Tonsillotomes,  464 
Tonsillotom}',  463 

Tongue,   congenital   absence   or  mal- 
formation, 718 

cysts  beneath,  719 

enlargement  of,  see  macroglossia, 
718 

fibroma  of,  719 

ne\ats  of,  719 

papilloma  of,  719 

swallowing,  470 

tongue  tie,  719 
Topography,  cranio-cerebral,  361 
Torticollis,  causes   of,   161 

in  cervical  spondylitis,  474 

hematoma  of  sterno-mastoid,  161 

from  rheumatic  myositis,   161 

sj-mptoms,    162 

treatment,  162 
Trachea,  foreign  bodies  in,  481 
Tracheoscopy,   484 
Tracheotomy,  506,  509 

anesthesia  in,  40 

for  thymic  asthma,  51 1 
Tracheo-stenosis,    510 
Trauma,  of  kidney,  649 

operative,     causing     synechias     in 
nares,  451 
Traumatic  gangrene,  149 
Traumatism,  accidental  or  operative, 

in  relation  to  shock,  46,  48 
Transplantation  of  tendons,   171,   173 
Transference  of  nerves,  406,  413 
Treatment,   post-operative,   51 
Trendelenberg's  operation  for  extro 

version   of  bladder,  667 
Tridermic  tumors,  78 
Trochanter  major,  separation  of,  294 
Trusses,  43 

author's  for  umbilical  hernia,  605 

for  femoral  hernia,  616 

for  inguinal  hernia,  612 
Tubercular  abscess,  225 

in   hip   joint   disease,  237,  243 

reinfection   of,   228 

treatment  of,  251 
Tuberculosis,   112 

age  of  incidence,   113 

of  bones  and  joints,  223 
of  the  ankle,  263 


Tuberculosis — Continued. 
dactylitis,  268 
of  the  elbow,  264 
diagnosis  and  symptoms : 

atrophy,  229 

differential    diagnosis,    230 

fluctuation,  229 

heat,   228 

muscular  spasm,  230 

pain   and  tenderness,   228 

redness,  229 

shortening      and      displace- 
ments, 230 

swelling,  229 
hip  joint,  see  hip  joint  disease, 

joints  affected  at  various  ages, 

235  _ 
knee  joint,  see  tuberculosis  of 

knee  joint,  255 
prognosis,  230 
pathology  of  bone,  224 
pathology  of  joint,   225 
of  ribs  and  other  bones,  270 
of   sacro-iliac   articulation,   266 
of   sterno-clavicular   joint,    269 
of  shoulder,  265 
of   spine,  434 
of  tarsal  bones,  264 
of  various  other  bones,  270 
of  wrist  joint,  266 
treatment,   114,  231 

by  local  hyperemia,  116,  233 
by  antiseptic  injections,  232 
by  operation,  234 
by  rest,  231 

causes,  predisposing,    113 

clinical   manifestations,    113 

diathesis,  112 

drugs  in,  115 

of  epididymis,  690 

of  glands,  329 

heredity  of,  112 

hyperemia    in    localized,    116 

infection,  sources  of,  113 

of  kidney,  659 

of  larynx,  479 

of  lymph  nodes,  329 

of  meninges,  in  spinal  caries,  444 

of  peritoneum,   556 

of  pleura,  516,  517,  523 

of  testicle,  690 

tuberculin   in,    115 

treatment,   114 
Tumors,   abdominal,  dangers  of,  82 


788 


INDEX 


Tumors — Continued. 
of  auditory  canal,  66 
angioma,  83 
of  bladder,  74,  669 
carcinoma,  75 
chondroma,   68 
coccygeal,  gi 
congenital    of    spinal    and    sacral 

region,  8g 
cranial  meningocele  and  encepha- 

locele,   340 
cystoma,  8g 
dermoids,  78 

causing    intestinal    obstruction, 
82 
desmoid,   65 
enchondroma,  67 
fibroma,    64 
fibro-angioma,  64 
fibro-sarcoma,  64 
hydro-nephrosis,   655 
hydro-perinephrosis,    93,    655 
in   infancy   and   childhood,  62,  94 
intra-cranial,  360 
keloid,  65 

of  kidney,  72,  92,  660 
larynx,  480 
leiomyoma,  69 
lipoma,  67 

lymph-adenoma,    325,   337 
lymphangioma,  87 
lymphoma,  71 
lympho-sarcoma,   225 
of     lymph     vessels     and     lymph 

glands,  324 
myoma,  69 
myo-fibroma,  69 
myxoma,   66 
myxo-lipoma,  67 

nsevus,  72,  83,  84,  85,  86,  638,  719 
neuroma,  69 
©f  ovary,  81,  696 
osteoma,  68 

papilloma,   of  larynx,  480 
\      of  tongue,  719 
polypi,  66,  639 

of  auditory  canal,  66 

of  rectum,  67 
pneumatocele,  344 
rhabdomyoma,  69 
retention  cysts,  64,  91 
of  rectum,  67,  638 
of   spinal   and    sacral    regions,   89 
sarcoma,  71 

of  bladder,  74 


Tumors — Continued. 
of  kidney,  72 
of  testicle,  73,  689 
teratoma,  77 
of  tongue,  719 
tridermic,  78 
Turbinates,    malformation   or   hyper- 
trophy, 451 
Twins,  joined,  77 
Tympanic  membrane,  incision  of,  380 

inflammation   of,   375 
Tympanitis,    375 
Typhoid,  arthritis,  216,  218 
gangrene,    150 

Ulna,    dislocation    of,    backward    or 
laterally,  314 

forward,  316 

symptoms,   317 
treatment,  317 

fracture  of  shaft,  291 

separation    of    olecranon,    292 
Umbilicus,  position  in   infants,  532 

infection  of,  534 

malformations,  534 
Umbilical    hemorrhage,    536 
Uranostaphylorrhaphy,   713 

after-treatment    and    results,    717 
'  other  methods  of  operation,  717 
Urethra,  malformation  of,  see  atresia 
ani    urethralis,    635 

calculus    of,    675 

foreign  body  of,  675 

prolapse  in  female,  697 

rupture  of,  676 

inflammation  of,  685 
Urethritis,   685 
Urine,  examination  of,  38 
Uronephrosis,  759 
Urotropin,  Crowe  on,  753 

Vaccine  therapy,  132 
in  abscesses,  134 
in  cystitis,   134 
in  mixed   infections,   134 
in   staphylococcus   infections,    133 
kinds  of  infections  treated  by,  133 
in  bone  necrosis,   134 
preparation   of    vaccine,    132 
in  rheumatism,  133 
in  localized  tuberculosis,  134 
in  gonorrhceal  vulvovaginitis,   133 

Vagina,  malformation  of,  see  atresia 
ani  vaginalis,  633 

Vaginitis,  698 


INDEX 


789 


Varicocele,  690 

Vegetations    about   anus,   642 

Verneuill,    on    dermoids    of    testicle, 

80 
Vesical  calculus,  670 
etiologA-,    670 
diagnosis,  671 
prognosis,  672 
sj'mptoms,  671 
treatment,  672 
litholapaxy,  673 
lithotomy,  suprapubic,  674 
Vicious  union,   refracture   for,  279 
Virchow,  on  congenital  tuberculosis, 

112 
Voivulus,  594 
symptoms,   594 
treatment,  594 

operation      for      obstruction      of 
bowel,  595 
Von    Mosetig   Moorhof's    sequestrec- 
tomy, 2og 
Vulpius,    tenotomy    and    transplanta- 
tion, 174 
Vulvitis,  698 

Vulvovaginitis,  prevention,  700 
isolation  of,  700 
simple,  etiology,  698 
prognosis,  698 
treatment,  698 
specific,  etiology,  699 
diagnosis,  699 
symptoms   and   course,  699 
treatment,   699 
treatment,  700 


Warts,  about  anus,  642 
Washburn  brace,  446 
Wasserman,     diagnosis     of     syphilis 
from  blood,   120 
serum  reaction  for  syphilis,  121 
Weak  ankles,  739 
braces  for,  740 
Webbed  fingers  and  toes,  743 
Weight,   57 
White    swelling    of    the    knee    joint, 

255 
Whiting,  on  clinical  history  of  sinus 

thrombosis,  387 
Whitman  brace  for  flat  foot,  7^;^ 
Wilms,    Max,    on    dermoid    tumors, 

79 
Wilson,    on    degree    of    pressure    in 

Bier  treatment,  128 
Wood's,    operation    for    extroversion 

of  the  bladder,  665 
Wrench,   Peters',  259 
Wright,  on  opsonins  and  opsonic  in- 
dex, 120 
Wright,  G.  A.,  on  amputation  at  hip, 
254,  255 
on  erasion  of  joints,  260 
on   acute   periostitis,  202 
Wrist  joint,  tuberculosis  of,  266 

deformit}',  197,  291 
Wry  neck,  see  torticollis,  161 

X-ray,  contraindications,  34,  35 
in  diagnosis,  34 

Zahorsky,    treatment   of   intussuscep- 
tion, 759 


"A  GREAT  WORK" 

"The  factors  of  inheritance,  developmental  patholog}^  excessive  reaction 
to  stimuli,  and  others  that  readily  will  occur  to  the  thoughtful  student,  serve 
to  engender  a  group  of  diseases  in  children  to  which  the  adult  is  a  stranger, 
and  also  powerfully  to  modify  those  diseases  which  they  share  in  common 
with  adults.  Of  all  these  factors,  that  of  development  is  undoubtedly  the 
most  significant.  The  fact  that  the  child  is  unfinished,  is  still  growing,  ex- 
erts a  profound  influence  in  shaping  its  physiology. 

"In  internal  medicine,  to  be  sure,  these  considerations  have  received  a 
certain  degree  of  recognition,  although,  in  our  opinion,  not  nearly  enough. 
But  in  surgery,  where  one  would  think  that  they  ought  to  have  even  more 
weight,  they  have  been  strangely  ignored  and  neglected. 

"Dr.  Kelley  stands  almost  alone,  so  far  as  the  literature  of  this  country 
is  concerned,  in  his  demonstration  of  the  deep-lying  differences  which  dis- 
tinguish and  separate  the  surgical  diseases  of  children  from  those  of  adults, 
and  in  his  clinical  application  of  these  differences. 

"We  have  no  hesitation  in  declaring  that  Doctor  Kelley 's  book  is  a 
great  work,  not  alone  in  its  actual  content,  but  in  the  broad  viewpoint  in 
which  it  sets  the  whole  subject  of  which  it  treats.  Clinically,  it  is  as  com- 
plete as  care  and  judgment  could  make  it.  Scientifically,  it  is  almost  epochal. 
The  present  edition  contains  a  great  deal  of  new  matter ;  not,  as  the  author 
says,  everything  new  that  has  been  proposed,  but  such  as  is  likely  to  have 
permanent  interest  and  value.  We  trust  it  will  meet  with  the  reception  and 
adoption  that  it  deserves."" 

American  Journal  of  Clinical  Medicine,  August,  1914,  Reviewing  Kelley's  "Sur- 
gical  Diseases   of   Children,"   published  by  E.   B.  Treat   &  Co.,  New  York. 


"The  Most  Authoritative  and  the  Most  Popular" 

When  the  first  edition  of  this  work  appeared  in  l!)i)!),  it  represented 
tlie  first  attempt,  by  an  American  author,  at  least,  to  treat  the  subject  of 
surgery  as  appHed  to  children  in  a  manner  commensurate  with  the  degree 
of  importance  to  which  it  is  entitled,  and  the  book  received  a  well-merited  and 
unusually  enthusiastic  reception.  Previous  to  this  time  one  had  to  search 
through  almost  innumerable  journal  articles,  text-books  and  treatises,  de- 
voted mostly  to  adult  surgery,  and  to  cull  what  was  applicable  in  handling 
surgical  diseases  as  they  occur  in  children.  This  was  particularly  true  for 
those  whose  reading  had  to  be  confined  to  books  and  journal  articles 
written  in  English ;  while  even  those  whose  accomplishments  included  a 
reading  knowledge  of  French  and  German  often  had  to  form  their  own  con- 
clusions as  to  the  applicability  of  certain  procedures  common  enough  in 
adult  practice  but  of  comparatively  unknown  value  when  applied  in  the 
treatment  of  infants  and  children. 

This  chaotic  condition  ended  with  the  appearance  of  Kelley's  work;  for 
he  collected  and  co-ordinated  all  this  scattered  information,  added  much 
from  his  own  vast  experience,  and  wrote  a  book  based  on  the  pathology  and 
physiology  of  child  life,  indicating  in  a  masterly  way  the  proper  methods 
of  procedure  under  these  special  conditions.  Since  that  time,  a  number  of 
books  devoted  to  this  subject  have  appeared ;  but  the  reviewer  has  failed  to 
find  one  whose  author  has  covered  the  ground  so  thoroughly  or  with  the  same 
unerring  instinct,  one  might  say,  as  to  the  choice  of  material  and  manner  of 
presentation  as  the  pioneer  writer  in  this  field. 

The  recent  rapid  progress  in  medicine  and  the  allied  sciences,  especially 
due  to  the  development  of  trained  laboratory  workers  along  the  lines  of  path- 
ology, bacteriology,  serology,  and  experimental  medicine  and  surgery,  with 
the  resulting  changes  in  the  conception  of  many  diseases  on  the  one  hand, 
and  modifications  and  refinements  in  technique  on  the  other,  made  a  revision 
of  the  work  necessary.  The  author  has  done  this  so  thoroughly  that  the 
entire  subject  has  been  brought  up  to  date  in  the  strictest  sense  of  the  term ; 
and.  in  the  o])inion  of  the  reviewer,  the  revising  has  resulted  in  firmly  estab- 
lishing this  book  as  the  most  authoritative  as  well  as  the  most  popular  work 
on  the  surgical  diseases  of  infants  and  children  in  this  country,  if  not 
throughout  the  English-speaking  world.— 77/r  Post  Graduate,  Nciv  York. 


"This  volume  is  in  every  sense  something  more  than  a  mere  chronicle 
of  surgical  pediatrics.  It  strives  at  and  attains  a  higher  goal.  There  is  a 
clear  and  consistent  effort  to  present  to  the  careful  reader  the  practical 
essential  differences  between  child-surgery  and  adult-surgery;  between  child- 
pathology  and  adult-pathology.  Xor  is  this  all — the  book  is  nev  and  up-to- 
date  in  the  best  sense  because  it  not  alone  gives  full  credence  and  value  to 
the  importance  of  experimental  medicine  and  surgery,  but  painstakingly  seeks 
to  make  clear  the  relationship  and  inter-dependence  of  the  surgery  which 
in  the  past  has  erroneously  been  called  "practical'  and  that  which  has  with 
equal  error  been  styled  'theoretical'  or  'experimental.'  The  author  has 
wisely  decided  that  modern  surgery  must  necessarily  be  a  combination  of 
the  two.  and  the  skill  with  which  he  has  woven  the  intricate  woof  of  mod- 
ern surgical  physiology  and  pathology  into  the  stiong  basic  warp  of  well- 
recognized  surgical  principles  seems  to  the  reviewer  the  most  admirable 
fact  of  the  entire  work.  Finally,  the  author's  great  care  in  presenting  es- 
sential details  should  be  commented  on  favorably." 

The    Xew    York    Medical    Record,    reviewing    Kelley's   "Surgical    Diseases    of 
Children,"  published  bj^  E.  B.  Treat  &  Co.,   Xew  York. 


